ENT Topics 2018 4. Diseases of the External Nose & Complications .......................................

30
5. Nasal Trauma & Treatment ............................................................................... 31
Table of Contents 6. Epistaxis ..................................................................................................................... 33
7. DDx of Nasal Obstruction ................................................................................... 35
A. EAR ...................................................................................................................................... 3 8. Acute & Chronic Rhinitis ..................................................................................... 36
1. Anatomy & Function of the External & Middle Ear ................................... 3 9. Clinical Sx, Dx, Tx of Allergic Rhinitis ............................................................ 37
2. Anatomy & Function of the Inner Ear .............................................................. 4 10. Traumatic Lesions of the Facial Cranium ................................................. 38
3. Tuning Fork & Other Audiometrical Examinations ................................... 5 11. Paranasal Sinusitis in Childhood & Adults ............................................... 39
4. Otoneurological Examinations ........................................................................... 6 13. Cx of Paranasal Sinusitis .................................................................................. 40
5. Malformations & Diseases of the External Ear ............................................ 7 12. Tx of Paranasal Sinusitis .................................................................................. 41
6. Middle Ear & Pyramid Bone Traumas ............................................................. 8 14. Tumours of Nose & Paranasal Sinuses....................................................... 42
7. Diseases of the Eustachian Tube........................................................................ 9 15. Functional Anatomy of the Pharynx ........................................................... 43
8. Acute Purulent Otitis Media ............................................................................... 10 16. Diseases of the Nasopharynx ......................................................................... 44
9. Chronic Mesotympanal Otitis Media .............................................................. 11 17. Acute & Chronic Inflammation of Mesopharynx ................................... 45
10. Chronic Cholestamatous Otitis Media ......................................................... 11 18. Acute Tonsillitis. Specific Angina. ................................................................ 46
11. Intracranial Complications of Acute & Chronic Otitis Media ............ 12 19. Chronic Tonsillitis & 2ry Cx. ........................................................................... 47
12. Intratemporal Complications of Acute & Chronic Otitis Media ....... 14 20. Indications for Adenoidectomy & Tonsillectomy.................................. 48
13. Indications for Antrotomy, Mastoidectomy, Radical 21. Tumours of Mesopharynx & Laryngopharynx (Hypopharynx) ...... 48
Mastoidectomy. What does it mean? .................................................................. 15 22. Dysphagia & Its Management by the Family Doctor ............................ 49
14. Surgical Reconstruction of the Hearing Mechanism ............................ 16
15. Otosclerosis & Its Surgical Tx ......................................................................... 17 C. LARYNX ........................................................................................................................... 50
17. Toxic Damages & Circulatory Disturbances in Inner Ear ................... 17 1. Functional Anatomy of the Larynx. ................................................................ 50
16. Tumours in the External Ear & Middle Ear .............................................. 18 2. Malformations fo the Larynx............................................................................. 51
18. Acoustic Injury ...................................................................................................... 19 3. Trauma of Larynx, Therapy ............................................................................... 52
19. Meniere’s Disease. ............................................................................................... 20 4. Functional Disorders of the Larynx ............................................................... 53
20. Acoustic Neuroma & Its Early Diagnosis ................................................... 21 6. Acute Laryngitis In Childhood .......................................................................... 53
23. Differential Diagnosis of Tinnitus ................................................................. 21 5. Acute & Chronic Inflammation of Larynx .................................................... 54
21. Hearing Loss in Childhood ............................................................................... 22 7. Benign Tumours & Precancerous Diseases of Larynx ........................... 55
22. Function of Facial Nerve & Facial Nerve Palsy........................................ 23 8. Malignant Tumours of Larynx .......................................................................... 57
24. Otalgia. Otalgia irradiata. DDx. Task of Family Doctor. ....................... 24 9. Treatment of Laryngeal Cancer, Surgical Procedures for Laryngeal
25. Mastoiditis .............................................................................................................. 25 Carcinoma ...................................................................................................................... 58
10. Dyspnea Caused by Disorders of URT ........................................................ 58
B. NOSE & PHARYNX....................................................................................................... 26 11. Edema in Larynx .................................................................................................. 59
1. Functional Anatomy & Physiology of the Nose & Paranasal Sinuses. 12. Indications for Cricotomy, Tracheostomy + Technique ..................... 59
............................................................................................................................................. 26 13. Intubation or Tracheotomy. ........................................................................... 60
2. Examination of the Nose & Sinuses ................................................................ 27 14. Diagnosis & Management of Foreign Bodies in URT & LRT ............. 60
3. Value & Indication of Radiological Examination of Paranasal Sinus 15. DDx of Cervical Enlargements & Inflammation ..................................... 61
Drainage. ......................................................................................................................... 28 16. Ludovic’s Angina, Parapharyngeal & Retropharyngeal Abscess,
Cervical Phlegmon...................................................................................................... 62
K. Jury & K. Costello-Toft, 2018 1
 17. Corrosive Injury & Stenosis of Esophagus ................................................ 63
18. Foreign Bodies in Pharynx & Esophagus ................................................... 64
19. Diseases of Salivary Glands ............................................................................. 64
20. Stenosis of Larynx & URT ................................................................................. 65
21. DDx of Dysphonia ................................................................................................ 65
22. Palpation of Neck & Its Consequence in Practice................................... 66

D. PRACTICAL TOPICS ................................................................................................... 67

1. Examination of the External Auditory Meatus & Ear Drum................. 67
2. Examination of Hearing by Means of Tuning Forks ................................ 67
3. Audiograms ............................................................................................................... 67
4. Measurement of Hearing Loss .......................................................................... 67
5. Examination of Spontaneous Vestibular Symptoms ............................... 67
6. Cleaning of External Meatus .............................................................................. 67

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A. EAR
1. Anatomy & Function of the External & Middle Ear

Middle Ear Consists of:

Functions of External Ear
1. TM
• Non-acoustic = protection, self-cleaning (hairs, wax) 2. Ossicular chain
• Acoustic: 3. Eustachian (pharyngotympanic tube)
o Transmit sound waves to the sensitive middle ear structures in 4. Middle ear cavity
a discriminating way
o Alters amplitude of incoming sound wave Function of Middle Ear
o Amplifies selected frequency bands (2-4 kHz) • Keep transmission loss as small as possible & at certain frequencies,
o Wind-break by creating air turbulence à ↓ constant acoustic transmit virtually all the E of the vibrating air to the inner ear fluid
effect of moving air
• Equalize static air pressure via Eustachian tube
o Plays a role in the “spatial” hearing of sounds
• At 1 kHz = sound E transmitted is most effective
o Helps in localization of sounds
Middle Ear Blood Supply
External Ear Blood Supply
• Deep auricular & tyampic br of internal maxillary
• Skin & Muscles = post auricular a (ECA) & Ant auricular a (spfc
temporal) • Stylomastoid br of post auricular
• EAM = post auricular, int maxillary & temporal aa
Middle Ear Innervation
External Ear Innervation • Auriculotemporal br of mandibular
• Skin & muscles = auricular br (Vagus), auriculotemporal br • Auricular br of Vagus
(Mandibular), lesser occipital & greater auricular (cervical plexus • Tympanic br of Glossopharyngeal
C2&3)
• EAM = auriculotemporal branches of the mandibular n & vagus

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2. Anatomy & Function of the Inner Ear

Inner Ear Division:

• Osseous Labyrinth
o Vestibule
o 3 semicircular canals
o Cochlea
§ Scala vestibule (sup)
§ Scala tympania (inf
§ Helicotrema = how the scala communicate w each
other (Small opening)
§ Cochlear duct = hearing receptors are localized here
o Perilymph
• Membranous Labyrinth = located wi bony labyrinth, suspended in
perilymph, filled w endolymph
o Vestibular labyrinth
o Cochlear labyrinth à scala media, Organ of Corti
• Internal auditory meatus
• CN VIII

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3. Tuning Fork & Other Audiometrical Examinations Pure Tone Audiometry
• Threshold is lowest intensity level at which px can hear ton 50% of
Range of Frequencies Audible to Human Ear time
• 20 to 20,000 Hz • Thresholds obtained for each ear at 250, 500, 1000, 2000, 4000, 8000
• Most sensitive frequencies: 1000-4000 Hz Hz
• Range of Human speech = 500 to 2000 Hz • AC thresholds are obtained w headphones & measure outer, middle,
inner ear & auditory n function
Tuning Fork • BC thresholds obtained w bone conduction oscillators which bypass
• Sensitivity depends on which tuning fork is used = 256 Hz, 512 Hz, outer & middle ear
1024 Hz • Degree of hearing loss = basis of pure tone average (PTA) at 500,
• 512 Hz has the greatest sensitivity 1000, 200 Hz
• Rinne Test • Conductive Hearing Loss (HL) = BC N, AC not normal
o 512 Hz tuning fork is struck & held firmly on mastoid process o Gap btw AC & BC thresholds >10 dB (an air-bone gap)
to test bone conduction (BC) • Sensorineural HL = both AC & BC ↓ normal
o Tuning fork is then placed beside the pinna to test air o Gap btw AC & BC <10 dB (no air-bone gap)
conduction (AC) • Mixed HL = both air & bone conduction thresholds < normal
o If AC >BC = + o Gap btw AC & BC >10 dB (air-bone gap)
• Weber Test
o 512 Hz tuning fork is held on vertex of head & px states Speech Audiometry
whether it is heard centrally (Weber negative) or is lateralized • Speech Reception Threshold
to 1 side (Weber R or Weber L) o Lowest hearing level where px can hear 50% of 2 syllable
o Can place vibrating fork on px’s chin while they clean their words (spondee words)
teeth or directly onto teeth to elicit more reliable resp o Suspect retrocochlear lesion or functioninal hearing loss
o Will only lateralize if difference in hearing loss btw ears is o Used to assess reliability of pure tone audiometry
>6dB • Speech Discrimination Test
o Weber test lateralization = ipsilateral conductive hearing loss o % of words px correctly repeats from list fof 50 monosyllabic
or contralateral sensorineural hearing loss words
o More sensitive in detecting conductive hearing loss than Rinne o tested at 40 dB above px’s SRT, therefore degree of HL is
taken into account
o px w N hearing or conductive HL score >90%

Impedance Audiometry
• Tympanogram
o Eustachian tubes equalize pressure btw external & middle ear
o Graph comp;liance of middle ear system against a P gradient
ranging from -400 to +200 mmH2O
o Normal = -100 to 50 mmH2O

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 • Static Compliance 4. Otoneurological Examinations
o Volume measurement reflecting overall stiffness of middle ear
system Acoustic Stapedial Reflexes
o Normal: 0.3-1.6 cc • Stapedius mm contracts in resp to loud sound
• Acoustic Stapedial Reflexes • Acoustic reflex threshold = 70-100 dB > hearing threshold
o Stapedius mm contracts in resp to loud sound • Acoustic reflex decay test = ability of stapedius m to sustain
o Acoustic reflex threshold = 70-100 dB > hearing threshold contraction for 10 s at 10 dB
o Acoustic reflex decay test = ability of stapedius m to sustain o Cochlear HL = 25-60 dB threshold
contraction for 10 s at 10 dB o Retrocochlear HL (acoustic neuroma) = absent reflexes or
§ Cochlear HL = 25-60 dB threshold marked reflex decay (>50%) wi 5 s
§ Retrocochlear HL (acoustic neuroma) = absent reflexes
or marked reflex decay (>50%) wi 5 s Auditory Brainstem Response
• Measures neuroelectric potentials (waves) in resp to a stimulus in 5
different anatomic sites à site of lesion
• Delay = cochlear or retrocochlear abnormalities
• Does not require volition or co-operation à good for kids &
malingerers

Otoacoustic Emissions
• Objective test of hearing here a series of clicks is presented to the ear
& the cochlea generates an echo which can be measured
• NB screening
• Can be used to uncover normal hearing in malingering px
• Absence of emissions can be due to hearing loss or fluid in middle ear

K. Jury & K. Costello-Toft, 2018 6

5. Malformations & Diseases of the External Ear
4. Perichondritis = after surgery, ear piercing,
Malformations: Congenital à common, vary from mild to severe • Tx = parenteral Abx & incision; removal of piercing
1. Protruding ears “bat ears” = absence of antihelical fold in the auricular
cartilage 5. Chondrodermatitis chronicis helicis = painful ulcerated lesion on rim;
• Surgical correction ~ 4 y (pinnaplasty) elderly
• Remove for histology
2. Accessory auricles = small tags, often containing cartilage on a line btw
the angle of the mouth & tragus 6. Furunculosis = Staph infection of hair follicle
• Abx, incisions & drainage
3. Preauricular sinus = small blind pit that occurs most commonly ant to
root of helix +/- bilat, +/- familial 7. Ramsay Hunt Syndrome (Herpes Zoster Oticus) = herpetic eruptions on
• If recurrently infected à excision TM, meatal skin, concha, postauricular groove
• CNVII & VIII
4. Microtia = failure of development of pinna (acrotia = complete absence of • VZV
pinna) • Cx = sensorineural HL
• Assoc’d w Treacher-Collins Syndrome • Tx: analgesics, antiviral ointment
• Tx: Prosthetic ears attached by bone-anchored titanium screws +
bone-anchored hearing aid Trauma
1. Minor lacerations = canal skin à Q-tip injury or unskilled physician,
Diseases: Acquired usually no sequelae

Inflammation 2. Major Lacerations = GSW, MVC, fights

1. External Otitis = inflammation of meatal skin à pinna & epidermal layer • Careful tx
of TM • Cx: stenosis of ear canal
• Hot & humid climates; swimmers
• S aureus, B prteus, E Coli, Canadida 3. Hematoma of Auricle (Othematoma) = direct blow to head à
• Tx: Burrow solution strip, Abx, antimycotics, steroid anti- extravasation of blood & serum beneath perichondrium
inflammatory drugs • Tx: aspiration (daily), firm pressure dressing, Abx, incision à
drainage
2. Malignant (necrotizing) external otitis = Skull Base Osteomyelitis
• Pseudomonas, diabetics, IS drugs, rare cx of otitis externa Cancer: SCC & BCC à Topic 16
• Otalgia & purulent otorrhea refractory to medical tx, granulation
tissue on floor of auditory canal Other: Frost Bite
• Cx = CNVII> X > XI nerve palsy, systemic infection, death • Exostoses = bony protruberances in ext auditory canal composed of
• Tx: High dose IV Abx (tobramycin, ticarcillin, 3rd gen cephs) lamellar bone; no tx
• Cerumen Impaction = conductive HL, +/- vertigo, tinnitus, otalgia,
3. Acute dermatitis à extension of otitis externa à topical neomycin or aural fullness; Tx: ceruminolytic drops, syringing, manual
chloramphenicol debridement
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6. Middle Ear & Pyramid Bone Traumas Tx
• ABCS
Middle Ear Diseases • Medical = expectant, prevent otogenic meningitis
1. Trauma • Surgical = explore temporal bone, indications:
2. Acute/Chronic Otitis Mediaà Topics 8-12 o CN VII palsy (immediate & complete)
3. Mastoiditis à Topic 25 o Gunshot wound
4. Otosclerosis à Topic 15 o Depressed fracture of EAM
5. Aero-Otitis à no topic o Early meningitis (mastoidectomy)
o Bleeding intracranially from sinus
Blunt Trauma: Temporal Bone Fractures o CSF otorrhea à may resolve spontaneously
• Characterized as longitudinal or transverse relative to the long axis of • Pyramidal fractures à conservative +/- prophylactic Abx
the petrous temporal bone
• Temporal bone fractures are rarely purely transverse of longitudinal
(often a mixed picture) Cx
• Etiology: blunt force trauma à MVC, assaults, falls (kids) • AOM +/- labyrinthitis +/- mastoiditis
• Hemotympanum can be indicative of temporal bone trauma • Sensorineural HL
• Meningitis/epidural abscess/brain abscess
• Post-traumatic choleastoma
• Disconnection of ossicular chain à surgery

Penetrating Trauma: minor (Q-tip) or Major (GSW to ear & temporal bone)
• Most common is self-inflicted --. Introducing foreign object, usually
heals wo sequelae

Traumatic Ear Drum Perforation

• Compression injury à slap, blast from gunshot
• Instrumental à hairpin, Q tip, matches
• Petrous bone fracture (temporal bone fractures)
• Sx = pain, bleeding, CHL
• Tx = cleaning of ear canal by suction using operating microscopy
Dx
o Reposition edges of ear drum à silic one or gelfoam patch
• Otoscopy o Abx, Tetanus toxoid
• Do not syringe or manipulate EAM due to risk of inducing meningitis o Urgent tampnotomy à facial n injury or subluxation of Stapes
via TM perforation (vertigo nystagmus, sensorineural HL)
• CT head
• Audiology, facil n tests (transver) Barotrauma Otitis Media
• Schirmer’s test, stepedial reflexes if CN VII palsy • Eardrum P < atmospheric P à edema, pain, deafness, tinnitus
• If suspecting CSF leak = look for halo sign, send fluid for beta-2 • Tx = decongestants, myringotomy
transferrin
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7. Diseases of the Eustachian Tube Sx
• Otalgia, hearing loss
• Popping sensation, cracking nose on swallowing
• Tinnitus, equilibrium disturbances, vertigo
• Retracted TM, amber discoloration of pars tensa
• Air bubbles in middle hear
• Conductive HL

Tx
• Nasal drop, antihistamine, Abx
• Adenotomy

Patulous ET
• ET is abnormally patent
Tubal Blockage
• Idiopathib, rapid weight loss, 3rd trimester preggo, MS
• O2, CO2, N & water vapour normally fill middle ear & mastoid
• When tube is blocked, first O2 is absorbed, but later other gases,
Sx
CO2, & N also diffuse out in to blood à negative P in middle ear &
• Autophony & breath sounds
retraction of TM
• Due to abnormal patency à P changes in nasopharynx are easily
• If negative P ↑ even more, it causes “locking” of the tube w collection
transmited to middle ear à mvmt of TM can be seen w inspiration &
of transudate à exudate à +/- haemorrhage
expiration (exagegerated if px breathes after closing the opposite
• Mechanical
nostril)
o Intrinsic = allergy, inflammation
Tx
o Extrinsic = tumour in nasopharynx or adenoids
• Acute = self-limiting
• Functional = collapse of tube due to ↑ cartilage compliance or failure
• Others = weight gain, potassium iodide PO is helpful
of active tubal-opening mech due to poor function of tensor veli
palatine • Chronic à cauterization of tubes or insertion of grommet

Etiology
• URTI
• Allergy
• Sinusitis
• Nasal Polyps
• Hypertrophic adenoids
• Nasopharyngeal tumour/mass
• Cleft palate à inadequate tensor palatine function
• Tumour = nasopharyngeal cc (adults)
• Barotrauma
• Abnormal spatial orientation of ET à Down’s (horizontal)
K. Jury & K. Costello-Toft, 2018 9
8. Acute Purulent Otitis Media • Otoscopy of TM
o Hyperemia
Acute Otitis Media o Bulging, pus may be seen behind TM
• Must have presence of all 3: o Loss of landmarks = handle & long process of malleus not
o Middle ear effusion (MEE) visible
o Middle Ear Inflammation (MEI)
o Acute onset of sx of MEE & MEI Dx
• Most frequent dx in sick kids, most common reason for Abx in kids • Hx
• 6-15 months, peaks in winter • Physical = febrile
• MEE on otoscopy = immobile TM, acute otorrhea, loss of bony
Etiology landmarks, opacification of TM, air-fluid level behind TM
• 1ry defect causing AOM: ET dysfunction/obstruction à • MEI on otoscopy = bulging TM w marked discoloration
stasis/colonization by pathogens (hemorrhagic, red, grey or yellow)
• Bacterial = S. pneumonia, H. Influenzae, M. catarrhalis, GAS, S.
aureus Tx
• Viral = RSV, influenza, parainfluenza, adenovirus • Observation for 48-72 h wo Abx since >80% resolve spontaneously
• Commonly due to bacterial/viral co-infection • Criteria for watch & wait:
o >6 m old
Risk Factors o no comorbidities (immunodeficiency, cardiac cx, abnorms of
• Non-modifiable = young age, FHx of OM, prematurity, orofacial head & neck, Hx of cx OM, Down’s)
abnorms, immunodeficiencies, Down syndrome, race, ethnicity o Illness not severe (fever <39 C, otalgia mild)
• Modifiable = lack of breastfeeding, daycare attendance, household o Parents are capable of recognizing worsening sx
crowding, exposure to cigarette smoke & air pollution, pacifier use • Maintain hydration
• Sx relief = acetaminophen, ibuprofen
Pathogenesis • Abx:
• Obstruction of ET à air absorbed in middle ear à negative P (irritant o 1st line = amoxicillin
to middle ear mucosa) à edema of mucosa w exudate/effusion à o 2nd line = 3rd gen ceph, azithromycin, clarithromycin
infection of exudate from nasopharyngeal secretions o If initial tx fails after 2-3 d à amoxicillin-clavulanate for 10 d
o If that doesn’t’ work, Ceftriaxons IM or IV
Sx
• Triad = otalagia, fever, conductive HL OM with Effusion
• Rarely: tinnitus, vertigo &/or facial n palsy • Presence of fluid in middle ear wo sx of ear infection
• Otorrhea if tympanic membrane perforated • Most common cause of pediatric hearing loss
• Infants/toddlers: • Follows AOM frequently in kids
o Ear tugging (alone not a good indicator) • Sx = CHL +/- tinnitus, fullness, +/- pain, low grade fever
o HL, balance disturbances (rare) • Tx = 90% resolve wi3 m
o Irritable, poor sleeping • Surgery = myringotomy +/- ventilation tubes +/- adenoidectomy
o V&D
o Anorexia
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9. Chronic Mesotympanal Otitis Media 10. Chronic Cholestamatous Otitis Media

Chronic Mesotympanol Otitis Media (or just Chronic Otitis Media) Cholesteatoma = Cyst composed of keratinized desquamated epi cells
• An ear w TM perforation in the setting of recurrent or chronic ear occurring in the middle ear, mastoid & temporal bone
infections • 2 types à congenital & acquired
• Chronic mucosal inflammation of the middle ear
• One of the most common infectious diseases Congenital
• Due to recurrent infections in childhood, re-infections from • “Small white pear” behind an intact tympanic membrane (ant & med
nasopharynx, ear drum perforation & ET disorders to malleus) or as CHL
• Believed to be due to an aberrant migration of external canal
Types ectoderm during development
• Benign = dry TM perforation wo active infection • Not assoc’d w OM/ET dysfunction
• Chronic Serous OM = continuous serous drainage (straw-coloured)
• Chronic Suppurative OM = persistent purulent drainage thru a Acquired = more common
perforated TM • 1ry = freq assoc’d w retraction pockets in pars flaccida à
cholestomas hard to visualize; crusting or desquatmated debris on lat
Sx surface
• Sx-free periods alternating w actue exacerbations • 2ry = pearly mas evident behind TM, freq assoc’d w marginal
• Conductive hearing loss performation, skin replaced mucosa of middle ear
• No pain, general condition is good • associated chronic inflammatory process à progressive destruction of
surrounding bony structures
Dx
• Otoscopy = central defect of TM, scarring of pars tensa +/- aural Sx
polyps • Hx of OM, ventilation tubes, ear surgery
• CT = opacity of the cell system +/- signs of bone destruction • Progressive hearing loss (usually CHL +/- sensorineural in late stage)
• Audiogram = CHL • Otalgia, aural fullness, fever
• Traction pocket in TM, keratin debris
Tx • TM perforation
• Abx ear drops, systemic & local Abx • Granulation tissue, polyp visible on otoscopy
• Conservative methods for drying ear à periodic cleaning • Malodorous, unilat otorrhea
• Aural polyps à surgical removal
• Mastoidectomy à eliminate infectious foci Dx: Audiogram & CT
• Tympanoplasty à reconstructing the conductive sound apparatus
Tx
Cx • No conservative
• Exacerbations can occur due to exogenous infection à bathwater • Surgical = mastoidectomy +/- tympanoplasty +/- ossicular
• Progression to cholestatoma & progressive hearing loss reconstruction

K. Jury & K. Costello-Toft, 2018 11

11. Intracranial Complications of Acute & Chronic Otitis Media • Dx
o CT/MRI
1. Extradural Abscess o NO lumbar puncture
2. Subdural Abscess • Tx
3. Meningitis o Burr holes or craniotomy tod rain empyema
4. Otogenic Brain Abscess o IV Abx
5. Lateral Sinus Thrombophlebitis o Mastoidectomy
6. Otic Hydrocephalus
3. Meningitis = inflammation of leptomeninges (Opia & arachnoid)
Factors Influencing Development of Cx • Acute & chronic OM
1. Age • Sx:
2. Poor SES o Fever, headache, neck ridigidty, photophobia, mental
3. Presence of MDR organisms irritability, N&V, drowsiness, delirius, coma
4. IC host o + Kernig & Brudzinski signs
5. Prefomed pathways à previous ear surgery, fracture of temporal o Papilledema
bone, perilymph fistula • Dx
6. Cholesteatoma o Contrast CT & MRI
o Lumbar puncture à CSF culture
Intracranial Complications • Tx
1. Extradural abscess = collection of pus btw bone & dura o Abx
• Acute & chronic infections o CS
• Sx o Surgical à myringotomy/cortical mastodiectomy
o Persistent headache on side of OM
o Severe ear pain 4. Otogenic Brain Abscess
o General malaise w low grade fever • Adults à cholesteatoma
o Pulsatile purulent ear discharge • Kids à AOM
• Tx • Sx
o Mastoidectomy o ↑ ICP à headache, N&V (projectile), ↓ LOC, confusion,
o Evacuated by removing overlying bone till the limits of stupor, papilledema
healthy dura o Localizing features
o Abx à min 5 d • Dx
o X-ray = midline shift, pineal gland calcification, gas in abscess
2. Subdural Abscess = collection of pus btw dura & erachnoid cavity
• Sx o CT
o Meningeal irritation = headache, fever, malaise, drowswiness, • Tx
neck rigidity, + Kernig sign o Chloramphenicol, 3rd gen ceph
o Thrombophlebitis of cortical vv à aphasia, hemiplegia, o Suction clearance, ear drops
hemianopia o Neurosurgical abscess drain
o ↑ ICP à papilledema, ptsosis, dilated pupil
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5. Lateral Sinus Thrombophlebitis = inflammation of inner wall of alteral
venous sinus w formation of a thrombus, occurs as cx of acute coalescent
mastoiditis, masked mastoidits, chronic suppuration of middle ear &
cholestatoma
• Sx
o Fever, headache, anemia, papilledema, tenderness along jug v
• Dx
o Blood smear & culture, CSF< imaging
• Tx
o Abx, mastoidectomy, anticoagulants, jugular ligation
• Cx = septicaemia, meningitis, cerebellar abscess, jug thrombosis

6. Otitic Hydrocephalus = ↑ ICP w normal CSF

• Kids & adolescents à acute & chronic OM
• Lateral sinus thrombosis + middle ear infection à obstruction of
venous return
• Thrombosis extends to sup sagittal sinus à impede function of
arachnoid villi to absorb CSF
• Sx
o Headache, diplopia (VI paralysis), blurred vision (papilledema
or optic atrophy), nystagmus
• Dx
o CSF P >300 mmH2O (N: 70-120)
• Tx
o ↓ CSF to prevent optic atrophy & blindness
o Acetazolamide & CS
o Repeated lumbar puncture +/- lumbar drain/lumboperitoneal
shunt
o Middle ear infection à Abx + mastoid exploration to find
sinus thrombosis

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12. Intratemporal Complications of Acute & Chronic Otitis Media 4. Labyrinthitis
• 3 types:
1. Mastoiditis o Circumscribed = thinning/erosion of bony capsule of
2. Petrositis labyrinth, usually of horizontal semicircular canal
3. Facial Paralysis o Diffuse Serous = diffuse intra-labyrinthine inflammation wo
4. Labyrinthitis: pus à reversible
a. Circumscibed o Diffuse Suppurative = diffuse pyogenic infection of labyrinth
b. Diffuse Serous w permanent loss of vestibular & cochlear functions
c. Diffuse Suppurative • Sx
o Vertigo, N&V, spontaneous nystagmus
1. Mastoiditis à topic 25 o Senosorineural HL à total HL
• Dx
2. Petrositis = spread of infection from middle ear & mastoid to petrous pt of o CT, MRI
temporal bone • Tx
• Sx o Systemic Abx
o Gradenigo’s syndrome à triad o Labyrinthine sedatives à prochlorperazine/dimenhydrinate
§ External rectus palsy (CN VI palsy) o Myringotomy
§ Deep-seated ear/retro-orbital pain (CN V) o Mastoidectomy
§ Persistent ear discharge
o Fever, headache, N&V, neck rigidity, facial paralysis,
recurrent vertigo
• Dx
o CT & MRI
• Tx
o Mastoidectomy
o Fistulas à curetted & enlarged to drain
o IV Abx before & after surgery

3. Facial Paralysis
• Cx of acute & chronic
• Sx
o Inflammation spreads to epineurium & perineurium à facial
paralysis
• Tx
o Myringotomy, mastoidectomy
o Nerve destroyed by granulation tissue à resection, grafting

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13. Indications for Antrotomy, Mastoidectomy, Radical Radical Mastoidectomy
Mastoidectomy. What does it mean? • Eradicate disease of middle ear *+& mastoid
• Mastoid, middle ear, attic & antrum are all exteriorized into external
Antrotomy ear by removal of post meatal wall
• Transcortical exposure of antrum thru the tunnel by drilling the • All remnants of TM, malleus, incus (NOT stapes), chorda tympani &
cortical bone at the Macewen triangle mucoperiosteal lining = removed
• Essentially it’s the mastoidectomy in kids • Opening of ET closed by packing a piece of m/cartilage into ET
• Antrum & aditis are widely opened from mastoid cortex to improve
aeration while leaving the post wall to the ear canal intact Indications:
• Only portion of air cell system is exenterated • When all cholesteatoma cannot be removed à invading ET, round
window niche, perilabyrinthine or hypotympanic cells
Indications • When previous attempts to eradicate disease have failed
• Mastoid evaluation in setting of tympanoplasty for chronic OM w • Infection approaches petrous apex
significant drainage • Removal of glomus tumour
• Persistent OM w effusion • Cc of middle ear à radical mastodiectomy + radiotx is alternative to
en bloc rmvl of temporal bone
Mastoidectomy
• Removes infected mastoid air cells resulting from infection when
medical tx is not effective
• Completely remove infectious foci & eliminate infection
• Performed smtms to repair paralyzed facial nn

Cortical = simple mastoidectomy/Schwartz Operation

• Extension of all accessible mastoid air cells, preserving post meatal
wall
• Indications
o Acute coalescent mastoiditis
o Incompletely resolved AOM w reservoir sign
o Masked mastoiditis

Modified Radical Mastoidectomy

• Removal of post meatal & lateral attic walls
• Irreversibly damaged tissues are removed, preserving the rest (TM
remnant, functioning ossicles, mucosa & function of ET) to
conserve/reconstruct hearing mech
• Indications:
o Cholestatoma confined to attic & antrum
o Localized COM

K. Jury & K. Costello-Toft, 2018 15

14. Surgical Reconstruction of the Hearing Mechanism Tympanoplasty = grafting of TM w inspection of ossicular chain +/-
reconstruction of middle ear hearing mechanism
1. Myringoplasty • Ossiculoplasty = repair of ossicular chain only
2. Tympanoplasty
5 Types of Tympanoplasty (Wullstein)
Myringoplasty = repair of TM wo inspection of ossicular chain, type of • I = perforation of TM repaired w graft à myringoplasty
tympanoplasty • II = perforation of TM w erosion of malleus
• Autograft materials = temporalis fascia, perichondrium o Graft is placed on incus/malleus remnant
• 2 techniques: • III = malleus & incus are absent, graft placed on stapes head à
o Underlay = margins of perforation are freshened & the graft myringostapediopexy/columella tympanoplasty
placed medial to the perforation or tympanic annulus, if large • IV = only footplate of stapes is present
& is supported by gel foam in the middle ear o Graft is placed btw oval & round windows
o Overlay = graft placed lateral to fibrous alyer of TM after • V = stapes footplate is fixed but round window is functioning
carefully removing all squamous epi from lat surface of TM o New window is created on horizontal semicircular canal &
remnant covered w graft à fenestration operation

Advantages
• Restore hearing loss à limited because it’s just TM repair only Indications
• Checking reinfection from EAM & ET (nasopharyngeal infection • Dry perforations
ascends easily via eustachian tube in the presence • Abx-resistant ear infection that has damaged TM
of perforation than otherwise). • FB/accident caused a rupture in TM
• Checking aeroallergens reaching the exposed middle ear mucosa à • Extra tissue accumulation around TM
persistent ear discharge
Cx
Cx • Recurrence of perforation
• Hearing loss • TM retraction
• Vertigo • Otorrhea
• Tinnitus • Choleasteatoma development
• Infection • Persistence/worsening of HL
• Sensorineural HL
CI • Infection
• Active discharge form middle ear
• Nasal allergy à control before surgery CI
• Otitis externa • Active infection of ear
• Ingrowth of squamous epi into middle ear • Choleasteatoma
• When other ear is not suitable for hearing aid rehabilitation • Medical reasons that CI surgery
• Kids < 3 y

K. Jury & K. Costello-Toft, 2018 16

15. Otosclerosis & Its Surgical Tx 17. Toxic Damages & Circulatory Disturbances in Inner Ear

Otosclerosis Drug Ototoxicity

• Fusion of stapes footplate to oval window so that it cannot vibrate
• 2nd most common cause of CHL in 15-50 y olds (after cerumen Aminoglycosides
impaction) • Streptomycin & gentamicin (vestibulotoxic), kanamycin, tobramycin
(ochleotoxic)
Etiology • Toxic to hair cells by any route = oral, IV, topical (if TM perforated_
• AD, variable penetrance approx. 40% • Destroys sensory hair cells = outer 1st, inner 2nd à therefore
• F>M, progresses during pregnancy (hormone responsive) otoacoustic emisions are lost 1st)
• ↑ freq HL developes earliest
Sx • Otoxoxicity occurs dd to ww post-treatment
• Progressive CHL first noticed in teens & 20s à sensorineural HL if • Must monitor w peak & trough levels when prescribed, esp if px has
cochlea involved neutropenia &/or history of ear/renal problems
• +/- pulsatile tinnitus • q24h dosing recommended (w amount determined by Cr clearance)
• TM normal +/- pink blush (Schwartz’s sign) assoc’d w • Aminoglycoside toxicity displays saturable kinetics, therefore, once
neovascularization of otosclerotic bone daily dosing presents less risk than divided daily doses
• Characteristic dip at 2000 Hz (Carhart’s notch) on audiogram • Duration of tx is the most important predictor of ototoxicity
• Absence of stapedial reflex • Tx = immediately stop aminoglycosides

Dx Salicylates = HL w tinnitus, reversible if discontinued

• Audiometry à pure tone & impedance
• Otoscopy Antimalarials (Quinines) = HL w tinnitus, reversible if discontinued; can
lead to permanent HL
Tx
• Monitor w serial audiograms if coping w loss Others
• Hearing aid (air conduction, bone conduction, BAHA = bone- • Many antineoplastic agents are ototoxic à weigh risks & benefits
anchored hearing aid) • Loop diuretics
• Stapedectomy or stapedotomy (w laser/drill) w prosthesis = definitive
tx Circulatory Disturbances
o Stapedectomy = fixed stapes removed, oval window closed b
CT & stapes replaced w wire prosthesis Acute Vestibular Paralysis = unknown cause
o Stapedotomy = head, neck & crura of stapes are moved, • Sx = rotatory dizziness, N&V, ataxia, spontaneous nystagmus, N
opening made in central pt of footplate à piston type hearing
prosthesis • Tx = anti-vertigo drugs, sedatives, IV rheomacrodex, CS, ABx

Cx Sudden deafness = unknown, no dizziness/balance problems

• Dizziness, SHL, total deafness, perilymph fistula • Tx = IV LMW-dextran, CS, Abx

K. Jury & K. Costello-Toft, 2018 17

16. Tumours in the External Ear & Middle Ear Middle Ear Tumours

Tumours of the External Ear Primary Tumours

1. Non-chromaffin paraganglioma = Globus Tumour = BENIGN
Benign • Arises from tympanic br of CNIX or from glomus bodies of jugular
bulb
1. Periauricular Sinus/Cyst = faulty union of hillocks of 1st and 2nd • CHL, tinnitus, pain, vertigo
branchial arches during pinna development • CN III, IV, V, VI, VII paralysis
2. Sebaceous cyst = postauricular sulcus, below & behind ear lobule • Tx = surgery, radiation, embolization
3. Dermoid cyst = rounded mass over upper pt of mastoid behind pinna
4. Keloids = trauma following piercing 2. Carcinoma, Sarcoma = MALIGNANT
5. Hemangioma = congenital tumours
6. Papilloma = wart, tufted growth or flat grey plaque, viral origin Secondary Tumours
7. Keratoacanthoma = raised nodule w central crater, resembles • From adjacent areas à nasopharynx, ext meatus, parotid
malignant tumour • Metastatic à cc of bronchus, breast, kidney, thyroid, GI
8. Neurofibroma = non-tender, form swelling

Malignant Tumours

1. SCC = helix; exophytic, slow growing, firm tumour

2. BCC = helix & tragus; men >50 y; non-exophytic, smooth, ingrowing
3. Melanoma = auricle; men; metastases in 16-50%

EAM
Benign Tumours of EAM
1. Osteoma = cancellous bone, post weall of bony meatus, mastoid;
single, smooth, bony, hard pedunculated tumour à post wal of
osseous meatus
2. Exostosis = multiple & bilat, smooth, sessile, bony swellings in the
deeper pt of meatus near TM; asx
3. Ceruminoma = tumour of solidified sweat glands which secrete
cerumen; smooth, firm skin-covered polypoid
4. Sebaceous Adenoma = sebeaceous glands of meatus; smooth, skin-
covered
5. Papilloma = similar to one seen on pinna

Malignant Tumours of EAM

1. SCC = meatus or 2ry extension of middle ear cc
2. BCC = similar to SCC

K. Jury & K. Costello-Toft, 2018 18

18. Acoustic Injury Sensorineural Hearing Loss
• Due to a defect in the conversion of sound into neural signals or in the
Hearing Loss transmission of those signals to the cortex
1. Conductive HL • Caused by disease of the inner ear (cochlea), acoustic n (CNVIII),
2. Sensorineural brainstem or cortex
3. Mixed • Retrocochlear = lesions of CNVIII
• Central deafness = lesions of central auditory connections
Conductive Hearing Loss • Congenital = result of anomalies
• Conduction of sound to cochlea is impaired • Acquired = genetic or non-genetic
• Can be caused by external & middle ear disease o Labyrinth infections
o External ear à obstructions o Trauma
o TM à perforation o Noise-induced
o Middle ear à fluid o Otoxtoxic drugs
o Ossicles à fixation or disruption o Meniere’s
o ET à obstruction o Acoustic neuroma
o DM, Hypothyroidism, kidney disease, MS, blood dyscrasias
Characteristics
• Negative Rinne test (BC >AC) Characteristics
• Weber = lateralized to worse ear • + Rinne Test (AC >BC)
• Normal absolute bone conduction • Weber lateralized to better ear
• ↓ frequencies more affected • bC reduced on Schwabach & absolute bone conduction tests
• Audiometry = BC >AC w air-bone gap • High freqs
o Bigger the air-bone gap = ↑ HL • No gap btw air & bone conduction curve on audiometry
• Loss is not >60 dB • Loss may be >60 dB
• Speech discrimination is good • Speech discrimination is poor
• Difficulty hearing in presence of noise
Management
• Removal of any canal obstructions Dx
• Removal of fluid à myringotomy +/- grommet insertion • Hx
• Removal of mass from middle ear à tympanotomy • Severity à audiometry
• Stapedectomy • Site of HL
• Tympanoplasty • Labs
• Hearing aid
Management
• Treat underlying cause if any

K. Jury & K. Costello-Toft, 2018 19

19. Meniere’s Disease. § Local application of gentamicin to vestibular end-
organ, results in complete SNHL
Meniere’s Disease: Endolymphatic Hydrops • *Before applying gentamicin, perform
• Episodic attacks of tinnitus, hearing lsos, aural fullness & vertigo gandolinium enhanced MRI to R/O CPA
lasting mins à hrs tumour as the cause of sx
• Diagnostic Criteria = must have all 3: o Surgical
o 2 spontaneous episodes of rotational vertigo ≥ 20 mins § Selective vestibular neurectomy or transtympanic
o Audiometric confirmation of SNHL (often ↓ freq) labyrinthectomy
o Tinnitus &/or aural fullness § Vestibular implants have recently been introduced
experimentally
Proposed Etiology • Must monitor bilateral ear as bilaterality occurs in 35%
• Inadequate absorption of endolymph à endolymphatic hydrops
(overaccumulation) that distorts the membranous labyrinth

Epidemiology
• Peak incidence 40-60 y
• Bilateral in 35% of cases

Sx
• Episodic vertigo, fluctuating ↓ freq SNHL, tinnitus & aural fullness
• ± drop attacks (Tumarkin crisis) ± N&V
o Drop attacks/Tumarkin’s otolithic crisis = sudden falls
occurring wo warning & wo LOC
• Vertigo disappears w time (mins à hrs), but hearing loss remains
• Early in disease = fluctuating SNHL
• Later stages = persistent tinnitus & progressive HL
• Attacks come in clusters & can be debilitating to px
• Triggers: ↑ salt intake, caffeine, stress, nicotine, alcohol

Tx
• Acute = bedrest, antiemetics, antivertiginous drugs (betahistine -
Serc), LMW dextran (uncommon)
• LT mgmt.:
o Medical
§ ↓ salt diet, diuretics (hydrochlorthiazide, triamterene,
amiloride)
§ Serc prophylactically to ↓ intensity of attacks

K. Jury & K. Costello-Toft, 2018 20

20. Acoustic Neuroma & Its Early Diagnosis 23. Differential Diagnosis of Tinnitus

Acoustic Neuroma
• Schwannoma of the vestibular portion of CN VIII
• Most common intracranial tumour causing SNHL
• Most common CPA tumour

Pathogenesis
• Starts in the internal auditory canal & expands into the
cerebellopontine angle (CPA), compressing cerebellum & brainstem
• When assoc’d w type-2 neurofibromatosis (NF2) = bilateral acoustic
neuromas, café-au-lait skin lesions, multiple intracranial lesions

Sx
• Usually presents w unilateral SNHL (chronic) or tinnitus
o In elderly, unilat tinnitus or SNHL is acoustic neuroma until
proven otherwise
• Dizziness & unsteadiness may be present, but true vertigo is rare as
tumour growth occurs slowly & thus compensation occurs
• Facial n palsy & trigeminal (V1) sensory deficit (corneal reflex) = late
cx
• Risk factors:
o Exposure to loud noise
o Childhood exposure to low-dose radiation
o Hx of parathyroid adenoma

Dx
• MRI w gandolinium contrast = GOLD STANDARD
• Audiogram à assess SNHL
• Poor speech discrimination relative to HL
• Stapedial reflex absent or significant reflex delay
• Vestibular tests = N/asymmetric caloric weakness (an early sign)

Tx
• Expectant mgmt. if tumour is v small or in elderly
• Definitive = surgical excision
• Other options = gamma knife, radiation

K. Jury & K. Costello-Toft, 2018 21

21. Hearing Loss in Childhood • Kids
o Speech is delayed or unclear
Hearing Loss in Childhood o Does not follow directions
• Hearing loss in the first few years of life can cause delays in speech, o Often says “Huh?”
language & cognitive delays o Turns TV volume up too loud
• Speech & language delays are 2ry & often preventable
• Early ID of HL & determination of permanent (SNHL) or temporary Dx
(usually CHL) is key • Babies = hearing screening <1 m, usually in hospital à
electrodiagnostic testing
Etiology o Otoacoustic emissions testing
• Genetic: most common in newborns o If abnorm à auditory brain stem evoked responses
o Syndromic = AD, AR, X-linked now identified • Kids = clinical examination & tympanometry
§ DiGeorge, Alport, Noonan, Usher syndromes o >6 m but <2 y response to sounds tested
o Nonsyndromic = 2/3, etiology unknown o >2 y à follow simple auditory commands
• Prenatal o >7 y à central auditory processing evaluation
o Congenital infections à SNHL
§ TORCH = Toxoplasmosis, Tx
o Teratogens = thalidomide, methyl mercury, retinoic acid, • Hearing aides
trimethadione • Cochlear implants
• Perinatal • Therapy to support language development à sign language
o Low birth weight, anoxia, low APGAR scores
o Hyperbilirubinemia, sepsis
• Postnatal
o Infections = Measles, Mumps, Rubella, Meningitis, Ear
infections
o Ototoxic meds
o OM
o Head injury
o Fe-def anemia
o Cerumen accumulation
• Unknown

Sx
• Babies
o Does not startle at loud noises
o Does not turn to sound source at 6 m
o Does not say single syllable words by 1 y
o Turns head if sees you, but not if you call name
o Hear some sounds, but not others
K. Jury & K. Costello-Toft, 2018 22
22. Function of Facial Nerve & Facial Nerve Palsy DDx

Facial Nerve: CNVII

• Emerges from pons on brainstem
• Motor: Controls muscles of facial expression, post belly of digastric,
stylohyoid & stapedius mm
• Sensory: small area around the concha of auricle
• Special sensory: Taste from ant 2/3 of tongue
• Parasympathetic: glands of head & neck, including:
o Submandibular & sublingual salivary glands
o Nasal, palatine & pharyngeal mucous glands
o Lacrimal glands
• 5 branches:
o Temporal
o Zygomatic
o Buccal
o Marginal mandibular
o Cervical

Facial Nerve Palsy

Etiology
• Supranuclear & nuclear (MS, poliomyelitis, cerebral tumours)
• Infranuclear

Tx
• According to etiology + provide corneal protection w artificial tears,
nocturnal lid, tarsorrhaphy, gold weighting of upper lid
• Facial paralysis that does not resolve à reanimation techniques to
restore function
o Facial n anastomosis
o Interpositional grafts
o Anastomosis to other motor n
o M transpositions

K. Jury & K. Costello-Toft, 2018 23

24. Otalgia. Otalgia irradiata. DDx. Task of Family Doctor. • Injuries of cervical spines
• Caries spine
Otalgia
• Earache à need to find cause Psychogenic Causes
• Pain may be functional in origin if no known causes discovered
Local Causes • Px should be kept under observation w periodic re-evaluation
• External Ear
o Furuncle, cerumen impacta, otitis externa, otomycosis, DDx
myringitis bullosa, Herpes Zoster, malignant neoplasms
• Middle Ear
o AOM, ET obstruction, mastoiditis, extradural abscess, aero-
otitis media, cc of middle ear

Referred Cuases
• Ear receives n supply from:
o CN V = aurculotemporal br
o CN IX = tympanic br
o CN X = auricular br
o C2 & C3 spinal nn

Via CNV
• Dental = caries, apical abscess, impacted molar, malocclusion
• Oral cavity = benign/malignant ulcerative lesions of oral cavity or
tongue
• TMJ disorders = Bruxism, OA, recurrent dislocation, ill-fitting
denture
• Sphenopalatine neuralgia

Via CN IX
• Oropharynx = acute tonsillitis, peritonsillar abscess, tonsillectomy,
benigng/malignant ulcers of soft palate, tonsil & its pillars
• Base of tongue = TB, malignancy
• Elongated styloid process

Via CNX
• Tumour or ulcerative lesion of vallecula, epiglottis, larynx or
laryngopharynx, esophagus
Via C2, C3
• Cervical spondylosis
K. Jury & K. Costello-Toft, 2018 24
25. Mastoiditis

Mastoiditis
• Infection (usually subperiosteal) of mastoid air cells, most commonly
seen approx. 2 w after onset of untreated or inadequately treated
suppurative OM
• Kids > adults

Etiology
• Acute = S. pneumonia, H influenza, M. catarrhalis, S. pyogenes, S.
aureus, P. aeruginosa

Sx
• Classic Triad:
o Otorrhea
o Tenderness to pressure over mastoid
o Retroauricular swelling w protruding ear
• Fever, hearing loss, ± TM perforation (late)
• CT radiologic findings = opacification of mastoid air cells by fluid &
interruption of N trabeculations of cells (coalescence)

Dx
• CT

Tx
• IV Abx w myringotomy & ventilation tubes à usually all that is
required acutely
• Cortical mastoidectomy:
o Debridement of infected tissue allowing aeration & drainage
• Indications for surgery:
o Failure of medical tx after 48 h
o Sx of intracranial complications
o Aural discharge persisting for 4 w & resistant to Abx

K. Jury & K. Costello-Toft, 2018 25

B. NOSE & PHARYNX Olfactory Nerves à smell & supply olfactory region of nose

1. Functional Anatomy & Physiology of the Nose & Paranasal Sinuses. Sensory Innervation
1. Ant ethmoidal n à ant & sup pt of nasal cavity (lateral wall &
septum)
2. Branches of sphenopalatine ggl à post 2/3 of nasal cavity (Septum
& lat wall)
3. Branches of infra-orbital nà vestibule of nose (med & lat sides)

Motor Innervation
1. Facial n = mimetic mm
2. Mandibular n (CNV) = masticatory mm

Autonomic Nerves
1. Parasympathetic n fibers from greater spfc petrosal n à nasal
glands; control nasal secretion; cause vasodilation in blood vessels of
nose

Sympathetic nn à upper 2/3 of thoracic segments of spinal cord à

vasoconstriction

K. Jury & K. Costello-Toft, 2018 26

2. Examination of the Nose & Sinuses
3. Posterior rhinoscopy à posterior nasal space (nasopharynx)
How to Examine the Nose a. Obstruction
1. Good Source of Light b. Drip
a. Semi-mobile = Bull’s lamp à 6 inches above & behind the c. Bleeding
left shoulder of px @ level of their ear d. Pain
b. Mobile = head lamp e. Aural sx (ET tube)
2. Instruments f. Inspection
a. Nasal specula i. Post nasal mirror à small mirror attached to shaft at
b. Indirect laryngoscopy mirror an angle of 110 à choanna, post ends of turbinates,
c. Post-rhinoscopy mirrors post septum & nasopharynx
d. Nasal & aural forceps ii. Nasopharyngoscope
3. Head mirror 1. Rigid = 2.8 or 4 mm à 0, 30, 120 angles
2. Flexible à many disavantages à need 2 hands
Examination of nose = 3 pts = external nose, ant & post rhinoscopy 3. Diagnostic nasal endoscopy = 4 mm; 2.8 mm
1. External Nose only in v narrow nasal cavity of kids
a. Skin à hardness, discoloration, swelling iii. Examination under anesthesia after palatal retraction
b. Structure iv. Digital palpation
c. Vestibule v. Radiological examination
d. Masses 4. Nasal Endoscopy
e. Mobility 5. Sinuses à imaging
f. Inspection a. Sphenoid
i. Deformity à congenital (clefts, sinuses) or acquired b. Maxillary via inf meatus
ii. Shape
iii. Swelling à inflammatory, cysts, tumours
iv. Ulceration à trauma, neoplastic, infective
v. Blockage
g. Palpation
i. Tenderness over supraorbital, infraorbital or mental
foramine à neuralgias
ii. Mobility or crepitus à fracture of nasal pyramid
iii. Deformities

2. Anterior Rhinoscopy
a. Vestibule
b. Cavity à Thiduchum’s speculum
c. Patency à tongue depressor, cotton
d. Probe à 4% lignocaine, palpated afterwards
e. Examination after vasoconstriction

K. Jury & K. Costello-Toft, 2018 27

3. Value & Indication of Radiological Examination of Paranasal Sinus Indications of X-ray
Drainage. • Acute inflammation
• Midfacial fractures
1. Conventional radiographs
2. CT Dx Value
3. MRI • Value is compromised by presence of superinmposed structures
4. US • Scar tissue from previous surgery on paranasal sinuses can mimic
sinus opacity
1. Conventional radiographs • Difficult to evaluate sphenoid sinus in occipitomental projection à
lateral sinus projection should be added – craniocaudal extent of
Waters view à occipitomental (nose-chin position, touch film) à open frontal & maxillary sinuses can also be evaluated w this technique
mouth b/c petrous bones are projected below maxillary antra
• X-ray from behind 2. CT à good for bony margins, not as good for soft tissue
• Maxillary sinus • Chronic sinusistis
• Frontal sinus • Trauma (Esp frontobasal fractures)
• Sphenoid sinuses • Tumours
• Zygoma • Malformation
• Nasal bone
• Superior orbital fissure Dx Value
• Compromised by metal-bearing dentures à artifacts
Caldwell View à occipitofrontal (nose-forehead) • Provide nonsuperimposed 1ry images of paranasal sinuses in coronal
• Frontal sinuses & axial planes
• Ethmoid sinuses • Sagittal images can be reconstructed secondarily from axial or coronal
• Maxillary sinuses scans, but are of poorer quality
• Zygoma
• Superior margin of orbit 3. MRI = good for soft tissue, not as good for bony margins
• Superior orbit fissure • Diseases involving paranasal sinus & cranial cavity or orbit
o Tumours
Lateral view à lat side of skull o Congenital malformations
• Ant & post extent of sphenoid, frontal & maxillary sinuses • Differentiating soft tissue lesions wi paranasal sinuses
• Sella turcica o Mucocele
• Ethmid sinuses o Cyst
o Polyp
• Alveolar process
• Distinguish btw solid tumour tissue & inflammatory reaction
• Mandible
CI = electrically controlled devices
Submentovertical (basal) à sphenoid > post ehtmoid > maxillary
• Cardiac pacemaker, insulin pump, cytostatic pump, cochlear implant
Right & left oblique à post ethmoid sinus, optic foramen
K. Jury & K. Costello-Toft, 2018 28
4. Ultrasound =A &B mode
• Follow-up of acute inflammatory processes à eliminate need for
extra X-rays
• Kids & pregnant women
• Less details than CT/MRI
• No 3D
• Frontal & Maxillary sinuses
• Ant ethmoid cells via medial canthus of the eye
• Middle & post ethmoid cells à via transocular route = extremely
challenging
• Sphenoid sinus IS NOT ACCESSIBLE

K. Jury & K. Costello-Toft, 2018 29

4. Diseases of the External Nose & Complications 3. Diseases of Nasal Vestibule

1. Cellulitis a) Inflammatory
2. Nasal deformities – saddle nose, hump nose, crooked/deviated nose
3. Diseases of nasal vestibule i) Pyodermas of Hair follicles = Staph
a. Inflammatory • Folliculitis if only hair
i. Pyodermas of hair follicles • Furuncle (purulent liquefaction) +/- fever if spread
ii. Vestibulitis • Tx = warm compress, analgesics
iii. Erysipelas o Fluoxacillin (systemic) + local chlortetracycline
b. Non-inflammatory • Cx = hematogenous spread to intracranial structures
i. Stenosis & atresia of Nares o May rupture spontaneously into nasal vestibule
o Become cellulitis of upper lip or septal abscess
1. Cellulitis = Strep or Staph à red, swollen tender
• Tx = Abx, analgesia compresses ii) Vestibulitis = diffuse dermatitis of nasal vestibule (S. aureus)
• Discharge + trauma à infection
2. Nasal Deformities • Acute à red, tender, crusts & scales
o Tx = clean, Abx-steroid, silver nitrate
a. Saddle Nose • Chronic à fissures & crusting
• Depressed bony, cartilaginous or both
• Trauma, septal resection, destruction (TB, syphilis) ii) Erysipelas = GAS, S. aureus, G- rods
• Tx = augmentation rhinoplast by filling dorus w cartilage, bone or • Spreads diffusely in skin & SC tissue
synthetic (silicone, Teflon) implant • Fever
• Demarcated areas à spread
b. Hump Nose • If spreads to eyelids risk of intracranial involvement
• Bone +/- cartilage • Tx = parenteral penicillin, moist compresses soaked in an antiseptic
• Tx = reduction rhinoplasty solution

c. Crooked/Deviated Nose b) Non-Inflammatory

• Crooked à midline of dorsum from frontonasal angle to tip is curved
in a C/S i) Stenosis & Atresia of Nares
• Deviated = midline is straight but deviated to one side • Surgical trauma
• Trauma + birth, childhood injuries not recognized (à growth) = • Destructive lesion
deviated/crooked • Congenital atresia = rare
• Tx = rhinoplasty, septorhinoplasty à correct outer appearance but • Tx = reconstructive plastic procedures
also function!

K. Jury & K. Costello-Toft, 2018 30

5. Nasal Trauma & Treatment • Septal abscess à cartilage necrosis w loss of nasal septum & dorsal
1. Nasal Bone Fractures saddling
2. Fractures of Nasal Septum • Meningitis via spread to cranial cavity via vasculature
3. Perforation of Septum
4. Naso-orbital Fractures 2. Fractures of Nasal Septum
• Front, side or below blows
1. Nasal Bone Fractures (Often + Septum Injury) • Buckles, fractures vertically, horizontally, crushed
• Force à injury • Pieces may overlap, pierce nearby structures à tears
• Open/closed
a) Jarjaway fracture (front blow) à ant nasal spine à runs
a) Depressed = frontal blow à lower thin part of nasal bones easily breaks horizontally à vomer
• Severe = open book fracture à nasal septum is collapsed & nasal b) Chevallet fracture (below blow) à vertically from ant nasal spine
bones splayed out à dorsum

b) Angulated = lateral blow à unilateral depression of nasal bone or many Clinical

fractures + septum deviation • Profuse epistaxis à septal hematoma à bilat obstruction à 2ry
fibrosis à hypertrophy of septum
Sx
• Swelling, raccoon eyes Tx
• Tenderness, nasal deformity • Hematoma draining
• Crepitus + mobility • Repositioning & supported w mucoperichodnrial flaps w mattress
• Epistaxis sutures & nasal packing
• Nasal obstruction
• Lacerations 3. Perforation of Septum à whistling
• Traumatic = most common = surgical or accidental
Dx • Pathologic = septal abscess, nasal myiasis, rhinolith or neglected FB
• Inspection, palpation, ant rhinoscopy or endoscopy, radiology causing pressure necrosis, lupus, TB, syphilis, Wegener’s
(Waters, R & L lateral views & occlusal view) granulmoma
• Drugs & chemicals = steroid sprays, cocaine, occupation (chromium
Tx plating)
• Simple à conservative • Idiopathic
• Open/closed reduction
• Rhinoplasty/septorhinoplasty Clinical
• Small ant perforations cause whistling sound during inspiration or
Cx expiration
• Septal fracture is covered by an intact soft-tissue envelope, danger of • Larger perforations = crusts that obstruct nose or causes severe
subpericondrial haemorrhage w hematoma formation that can be epistaxis when removed
infected
Tx = cause, alkaline nasal douches, bland ointment
K. Jury & K. Costello-Toft, 2018 31
4. Naso-orbital Fractures = direct force displaces the bones posteriorly

Clinical
• Telecanthus = abnorm distance btw medial canthi of eyelids = late
displacement of med orbital wall
• Pug nose = bridge of nose is depressed & tip turned upwards
• Periorbital ecchymosis
• Orbital hematoma = bleeding of ant & post ethmoidal aa
• CSF leakage = fracture of cribriform plate & dura
• Displacement of eyeball

Dx
• X-rays, CT

Tx
• Closed reduction
• Open reduction

K. Jury & K. Costello-Toft, 2018 32

6. Epistaxis Etiology
1. Local
Epistaxis = bleeding from nose • Nose
• Sign à must find cause!!! o Trauma
o Infection
Nose Blood Supply o FB
o Neoplasm
1. Septum o Atmosphere
• ICA à ophthalmic a à ant & post ethmoidal a o Deviated septum
• Ext carotid system • Nasopharynx
o Maxillary a à sphenopalatine a à nasopalatine & post medial o Adenoids
nasal br o Juvenile angiofbrioma
§ à greater palatine a à septal br o Malignancy
o Facial a à sup labial a à septal br
2. General
2. Lateral Wall • CV
• ICA à ophthalmic a à ant & post ethmoidal aa • Hematology
• EC System • Liver
o Post lat & nasal br • Kidney
o Greater palatine • Drugs
o Nasal br of ant sup detal • Mediastinal P (↑ venous P)
o Br of facial a • Acute infection
• Vicarious menstruation
EPISTAXIS BY LOCATION
1. Little’s Area à ant inf nasal septum above vesstibule Site
• Kisselbachs Plexus • Littles areas (90%)
o Ant ethmoidal • Above middle turbinate à ant & post ehtmoidal aa
o Septal br of sup labial • Below middle turbinate à septal br of sphenopalatine
o Septal br of sphenopalatine • Post nasal cavity à BQ to pharynx
o Greater palatine • Diffuse à systemic disorder
• ANTERIOR EPISTAXIS • Nasopharynx
2. Woodruff’s area à under post inf turbinate
• Sphenopalatine a à post pharyngeal a
• POSTERIOR EPISTAXIS

K. Jury & K. Costello-Toft, 2018 33

Anterior vs. Posterior Epistaxis
Anterior Posterior
Incidence More common Less common
Site Littles area Posteroosuperior pt of
Ant lateral wall nasal cavity à diff to
localize
Cause Trauma Spontaneous
HTN
Atherosclerosis
Age Kids, YA >40 y
Bleeding Usually mild à ant pressure Severe à
(pinch) hospitalization
Tx Trotter’s method Hospitalization à post
Cauterization nasal packing
Anterior nasal packing (24 h) Endoscopy cautery
Elevation of Ligation of vessels
mucoperichondrial flap Elevation of
Reassure, mild sedation, mucoperichondrial flap
hemodynamic, tx cause Reassure, mild sedation,
hemodynamic, tx cause

Tx
1. First Aid = Trotter’s method
2. Cauterization
3. Anterior nasal packing
4. Posterior nasal packing (when bleeding is post into throat à always
hospitalize!)
5. Endoscopic cautery à post bleeding
6. Elevation of mucoperichondrial flap & SMR operation à persistent or
recurrent bleeds
7. Ligation of vessels à ext carotid, maxillary a, ethmoidal aa

K. Jury & K. Costello-Toft, 2018 34

7. DDx of Nasal Obstruction

A. Short Duration
1. Furuncle & eczema of nostrils
2. Acute allergic rhinitis or sinusitis
3. Trauma = nasal pyramid fracture, submucosal hematoma
4. FB
5. Edema

B. Long Duration
1. Collapsing nasal alae
2. Stenosis of nostrils
3. Ant rhinitis sicca
4. Deviated septum
a. Ant dislocation
b. C-deformity
c. S-deformity
d. Spurs
e. Thickening
f. Etiology = trauma, development error
5. Chronic rhinitis/sinusitis
6. Hypertrophy or turbinates
7. Adenoids
8. Septal perforation
9. FB, rhinolith
10. Nasal polyps
11. Cephalocele
12. Tumours
13. Drugs = OCP, antiHTN, antidepressants

K. Jury & K. Costello-Toft, 2018 35

8. Acute & Chronic Rhinitis 2. Chronic Rhinitis

Rhinitis = inflammation& swelling of mucous membranes of nose à runny Predisposition

nose, stuffiness • Persistence of nasal infection (sinusitis, tonsillitis, adenoids)
• Chronic irritation
1. Acute Rhinitis – viral, bacterial irritative • Obstruction
• Vasomotor
a. Viral = common cold (coryza)
• Adenovirus, picornavirus, (rhinovirus, coxsackie…) a) Chronic Simple rhinitis
• Incubation: 1-4 d • Nasal obstruction, discharge, headache, swollen turbinates
• Illness: 2-3 w (Self-limiting) or infection spreads • à HT & edema of mucus membranes
• Tx = rest, fluids, analgesia (CI aspirin), 2ry infection à Abx
b) Hypertrophic rhinitis
b. Influenzal Rhinitis = A, B, C à 2ry bacterial infection • Thickening, esp of inferior turbinate
• May be compensatory (deviated septum)
c. Rhinitis Assoc’d w Exanthemas = Measles, Rubella, Chickenpox (precede • Tx = resection
rash sx by a few days)
c) Atrophic rhinitis
d. Bacterial Rhinitis • Roomy cavities, foul crust à 1ry or 2ry
• Non-specific
o 1ry = kids d) Rhinitis Sicca
o 2ry = on top of viral • Crust-forming, px in hot, dry aras
• Specific • Ant 1/3
o Diphtheria à penicillin, isolation, antitoxin
e) Rhinitis caseaosa
e) Irritative = exposure, trauma • RARE
• Exposure, trauma • Males, unilateral
• Nose filled w cheesy foul material
• Origin à chronic sinusitis?
• Granulomatous + bone destruction

Tx
• Treat case
• Irrigation w alkaline solution
• Decongestants à REBOUND!
• Systemic steroids
• Abx

K. Jury & K. Costello-Toft, 2018 36

9. Clinical Sx, Dx, Tx of Allergic Rhinitis Dx
Allergic Rhinitis = IgE immunologic response of nasal mucosa to air-born • History
allergens (dust, dander, pollen) à watery discharge, nasal obstruction • Physical
(edema), sneezing & itching (+ itchy pharynx, eyes, palate) • Total & differential blood count – eosinophilia
• Onset 12-16 h • Nasal smear – eosinophils
• Inhaled allergen + genetic predisposition • Skin test – ID allergen
• Seasonal vs. perennial (less severe, stuffy nose, anosmia, drop & • Nasal provocation test = crude
cough, hearing problems – ET block)
Tx
2 Phases • Avoidance of allergy = house cleaning
Acute Chronic • Treatment w drugs
Onset 5-30 min after exposure 2-8 hrs o Antihistamines
Cell Release His release Infiltration of o Sympathomimetics à phenylephrine, xylometazoline
inflammatory cells at o CS
site of Ag deposition o Na cramoglycolate = mast cell stabilizer
Sx Sneezing Swelling • Immuno tx
Rhinorrhea Congestion o Allergen given in gradually ↑ doses
Nasal blockage Thick secretion o Suppresses IgE
+/- bronchospasm o ↑IgG titre à binds allergen
o take for a year (at least à discontinue ~3 yrs)
Sx
Nasal Signs Cx
• Transverse nasal crease • Recurrent sinusitis (obstruction)
• Pale, edematous mucosa • Nasal polyps
• Swollen turbinates • Serous OM
• Thin watery discharge • Orthodontic problems à mouth breathing
• Bronchial asthma
Ocular Signs
• Edema=ma of lids
• Conjunctivitis
• Allergic shirrers

Otologic signs
• Retracted TM
• Serous OM (ET block)

Laryngeal Signs
• Hoarseness

K. Jury & K. Costello-Toft, 2018 37

10. Traumatic Lesions of the Facial Cranium • Le Fort III = craniofacial dysjunction = complete separation of facial
from cranial bones
Occurs in soft itssues, bones, both à car accidents, sports, personal • Sx = CSF rhinorrhea, periorbital hematoma, dish face, diplopia,
accidents, assault cerebral prolapse, anosmia
• Dx = otoscopy, Waters, posteroant, lat views, test hearing and balance
3 Regions of the Face • Tx = restore AW & stop haemorrhage, interdental wiring,
intermaxillary wiring using arch bars, wire slings from frontal bone,
1. Upper 1/3 = above level of supraorbital ridge zygoma or infraorbital rim to teeth or arch bars

a) Frontal sinus 3. Lower 1/3 = mandible & lower teeth

• Ant wall fracture
• Post wall fracture à dural tears, brain injury, CSF rhinorrhea Dx: radiology, inspection, palpation
• Injury to nasofrontal duct
Tx
b) Periorbital ridge • Surgery
• Periorbital ecchymoses, eyebrow flattening • Correction

c) Frontal bone à depressed/linear, w or wo separation

• Extend à orbit
• Brain injury, cerebral edema

2. Middle 1/3 = btw supraorbital ridge & upper teeth

a) Zygoma fracture = tripod fracture

• 2nd most frequent fracture (1st = nasal bones)
• Waters view X-ray
• /tx = only displaced needx tx à open reduction & wire fixation

b) Zygomatic arch #
• 2 fragments, 3 fracture lines
• X-ray = submentovertical & Waters
• Tx = open reduction, usually no fixation

c) Maxilla
• Le Fort I = transverse = abov & parallel to palate
• Le Fort II = pyramidal = passes thru nasal root, lacrimal bone, floor of
orbit, maxillary sinus, pterygoid plates

K. Jury & K. Costello-Toft, 2018 38

11. Paranasal Sinusitis in Childhood & Adults 1. Acute Sinusitis
• Adults: maxillary > ethmoid > frontal > sphenoid
Sinusitis = inflammation of sinus mucosa • Children: ethmoid cells (incomplete pneumatisation of others)
• Acute vs chronic o Multisinusitis
• Open vs. closed à inflammatory products can drain directly into o Pansinusitis
nasal cavity thru nasal ostra
Etiology: viral infection à 2ry bacterial infection
Etiology • S. pneumonia
• Nasal infections • S. pyogenes
• Swimming & diving • S. aureus
• Trauma • H. influenza
• Barotrauma • Morexella catarrhalis
• Dental infection à maxillary • K. pneumonia
• Anaerobes in mixed
Predisposing Factors
Sx
Local • Acute rhinitis + headache à worse on bending
• Obstruction of sinus ventilation & drainage o Ethmoid = pain over bridge of nose, med eyes
o Nasal packing o Frontal à ant wall & floor à med eye
o Deviated septum o Sphenoid à non-specific dull pain/pressure at centre of skull
o Hypertrophic turbinates • Fever, malaise, general body ache
o Edema of sinus ostra (allergy) • Redness/edema of cheek à maxillary (kids)
o Nasal polyps • Edema of eye
o Neoplasm
• Stasis of secretions in nasal cavity Dx
o Hyperviscosity à CF • Rhinoscopy, nasal endoscopy
o Obstruction • Sinus radiographs à opacification
• Previous bouts of sinusitis • US

Other
• Environment à pollution
• Poor general health

K. Jury & K. Costello-Toft, 2018 39

2. Chronic Sinusitis = months to years 13. Cx of Paranasal Sinusitis
• Often mixed aerobe, anaerobe
• Maxillary & ethmoid = when infection spreads beyond bony wall

Causes 1. Local
• Failure of acute to resolve a. Mucocele/mucopyocele = frontal >ethmoidal > maxillary
• Intranasal anatomic changes = deviated septum >sphenoidal à chronic destruction
• Co-morbid à chronic inflammation, trauma, allergy b. Mucous/retention cyst
c. Osteomyelitis à frontal bone, maxilla
Mech
• Poor ventilation of ostromeatal unit (stenosis/obstruction) à ↓ 2. Orbital
drainage à mucosa becomes swollen (esp n narrow ostromeatus) à a. Preseptal inflammatiory edema of lids à reactional
vicious cycle à changes in mucosa b. Orbital cellulitis à pus spreads into orbit
c. Orbital abscess
Sx d. Superior orbital fissure syndrome à pain, frontal headache,
• Vague, similar to acute but < severe paralysis
• Purulent nasal discharge e. Orbital apex syndrome = same as above + optic n, V3
• Foul smelling = anaerobe
3. Intracranial
• Nasal stuffiness
a. Meningitis
• Anosmia
b. Extradural abscess
c. Subdural abscess
Dx
d. Brain abscess
• X-ray e. Cavernous sinus thrombosis
• CT
• Aspiration & irrigation 4. Descending
• Rhino/endoscopy a. Otitis media
b. Pharyngitis & tonsillitis
c. Persistent laryngitis & tracheobronchitis

K. Jury & K. Costello-Toft, 2018 40

12. Tx of Paranasal Sinusitis Tx of Chronic Sinusitis à find cause, conservative à surgery

Aims Medical à symptomatic

• Reduce swelling • Abx (blood-spectrum)
• Eradicate infection • Decongestant nose drops
• Drain sinuses • Corticosteroid nasal spray
• Ensure sinus remains open • Saline irrigation
• <50% need aggressive tx à home remedies are actually useful • Heat tx
• Mucolytics
Tx of Acute Sinusitis • Antiallergic tx

Support: 1st 7-10 days à No Abx until >7 days 2. Surgery

• Saline nasal irrigation • Maxillary
• Decongestion o Intranasal antrostomy
• Antishistamines o Caldwell-Luc operation
• Expectorants • Frontal
o Intranasal drainage
Medical Tx o Trephonaton
• Abx = ampicillin & amoxicillin (à erythromycin & doxycycline) o External frontoethmoidectomy
• Nasal decongestion • Ethmoid
• Stream inhalation o Intranasal ethmoidectomy
• Analgesics o External ethmoidectomy
• Hot fomentation • Sphenoid = sphenoidotomy

Surgical 3. Functional Endoscopic sinus surgery

• Maxillary sinusitis: Puncture • Enlarge tight passages in middle meatus & ostiomeatal unit
o Sharp via inf meatus (below inf turbine) • Indications:
o Blunt via natural ostium in middle meatus o Sinusitis
• Frontal sinusitis à trephination (if risk for cx) o Obstructive nasal polyposis
o Sinus mucocele
o Removing FB, etc.
• CI: Osteomyelitis

K. Jury & K. Costello-Toft, 2018 41

14. Tumours of Nose & Paranasal Sinuses

Tumours of External Nose

1. Congenital
a. Dermoid cyst = simple, associated w sinus
b. Encephalocele or meningoencephalocele à herniation &
meningest through congenital defect
c. Glioma à nipped off encephalocele (60% extranasal) à firm
BQ swelling

2. Benign Tumours à Nasal skin

a. Rhinophyma à slow growing, HT of sebaceous glands on tip
of nose

3. Malignant Tumours
a. BCC (rodent ulcer)
b. SCC
c. Melanoma

Tumours of the Nasal Vestibule

1. Nasoalveolar Cyst
2. Papilloma
3. SCC

K. Jury & K. Costello-Toft, 2018 42

15. Functional Anatomy of the Pharynx Blood Supply
• Asc pharyngeal a
Nasopharynx • Ascending palatin br of facial a
• Skull base to soft palate • Descending palatine aa
• Choana with turbinates • Pharyngeal br of maxillary a
• Eustachian tube • Br of inf & sup thyroid aa
• Salpingopharyngeal fold
• Soft palate – post surface Innervation
• Pharyngeal plux (IX, X, XI)
Oropharynx • Glossopharyngeal n & vagus n& sup cervical ggl à pharyngeal br
• Soft palate to hyoid bone • Vagal br innervate all m (except stylopharyngeus glossopharyngeal)
• Functions: • Pharyngeal mucosa sensory by glossopharyngeal n
o Conduit for air & food
o Helps in pharyngeal phase of deglutition
o Forms pt of vocal tract for certain speech sounds
o Helps taste sensation à taste buds are present in base of
tongue, soft palate, ant pillars & post pharyngeal wall
o Provides local defense & immunity against harmful intruders
into the trachea & esophagus

Laryngopharynx
• Hyoid bone to inf border cricoid cartilage
• Functions:
o Common pathway for air & food
o Vocal tract for resonance
o Helps in deglutination
o Coordination btw pharyngeal mm & relaxation of
cricopharyngeal sphincter at upper end of esophagus à failure
à hypopharyngeal diverticulum

Muscles
• External layer = constrictors
o Sup constrictor
o mid constrictor
o inf constrictor = oblique line & inf cornu of thyroid cartilages
• Internal layers = elevators
o Stylopharyngeus mm (bone)
o Salpingopharyngeus mm (auditory tube)
o Palatopharyngeus (soft palate)
K. Jury & K. Costello-Toft, 2018 43
16. Diseases of the Nasopharynx 2. Acute Nasopharyngitis
• Acute inflammation of nasopharynx à isolated or pt of gen UAW
1. Adenoid Hyperplasia • Viral = cold, influenza
2. Acute Nasopharyngitis • Bacterial = strep, pneumococcus, H. influenza
3. Chronic Nasopharyngitis
4. Thornwaldt’s Disease (Pharyngeal Bursitis) Sx
• Dryness, burning above soft palate, ↑ cervical LN
1. Adenoid Hyperplasia = nasopharyngeal tonsils located at junction of roof
& post wall 3. Chronic Nasopharyngitis
• Physiological enlargement in childhood • Often assoc’d w chronic inflammation of nose, sinuses, pharynx
• Recurrent rhinitis, sinusitis, chronic tonsillitis à chronic adenoid • Smokers, drinkers, dust/fume exposure
infection à hyperplasia
• Allergy of URT Sx
• Postnasal discharge & crusting
Sx • Chronic adenoitidis
• Nasal
o Obstruction à mouth breathing Tx
o Discharge • Alkaline douche, steam
o Sinusitis à chronic maxillary
o Epistaxis à acute inflammation 4. Thornwaldt’s Disease = Pharyngeal Bursitis
o Nasal voice • Inflammation of pharyngeal bursa = a media recess = attachment of
• Aural notochord to endoderm of primitive pharynx
o ET obstruction à retracted TM & CHL (Chronic hearing loss) • = midline of post wall of nasopharynx in adenoid mass
o Recurrent attacks of acute OM
o Chronic sup OM Sx
o Serous OM (kids) • Persistent postnasal discharge w crusting
• General • Obstruction (Nasal) due to swelling
o Face (adenoid facies) • Dull occipital headache
o Pulm HTN • Recurrent sore throat
o Aprosexia (can’t concentrate)
• Low grade fever
Dx
Dx
• Ex post nasal space, nasal exam
• Post nasal exam
• Nasopharyngoscope
• Nasopharyngoscope
• Soft tissue lat radiography
Tx
Tx = adenoidectomy
• Abx

K. Jury & K. Costello-Toft, 2018 44

17. Acute & Chronic Inflammation of Mesopharynx Chronic Pharyngitis
• Hypertrophy of mucosa, seromucinous glands, subepithelial lymphoid
Acute Pharyngitis follicles, muscular
• Viral = COMMON = Rhino, influenza, parainfluenza, Measles, VZV,
HSV, CMV, EBV Etiology
• Bacterial = GAS (rheumatic fever, GN), diphtheria, Gonococcus • Persistent infection
• Fungal = Candida • Mouth breathing
• Parasitic = Toxoplasmosis • Chronic irritants
• Envoi pollution
Sx • Excessive voice use
• Mild • GERD
o Malaise, low fever
o Discomfort of throat Sx
o Congested parhynx (no lymphedema) • Discomfort/pain in throat
• Mod-severe • FB sensation
o Headache, malaise, high fever • Tiredness of voice
o Throat pain, dysphagia • Cough
o Pharynx à erythema, exudate, ↑ tonsils, lymphoid follicles on
post wall 1. Chronic Catharrhal Pharyngitis
• Very severe • Congestion of post pharyngeal wall w engorgement of vessels
o Edema of soft palate & uvula • Facuail pillars may be thickened
o Enlargement of cervical nodes • ↑ mucus secretion à covers mucosa

Dx 2. Chronic HT (granular) Pharyngitis

• Throat culture à bacterial • Thick, edematous w congested mucosa & dilated vessels
• Reddish nodules = HT of subepi lymphoid follicles
Tx • HT of pharyngeal bands
• Strep à penicillin or erythromycin • Edematous uvula
• Diphtheria à antitoxin + penicillin/erythromycin • Tx = voice rest, speech tx
• Gonococcal à penicillin, tetracycline o Warm saline gargles
o Mandl’s pain
o Cautery of lymphoid granules, electrocautery

3. Atrophic Pharyngitis = in px w atrophic rhinitis à crusty!

K. Jury & K. Costello-Toft, 2018 45

18. Acute Tonsillitis. Specific Angina. Tx
• Rest, fluids, analgesia
Acute Tonsillitis • Abx = penicillin (augmentin)
• 2 palatine tonsils = masses of lymphoid tissue situated in alteral wall
of orpharynx btw ant & post pillars Cx
• Part of Waldeyer’s Ring • Chronic tonsillitis
• Common in school-aged kids, adults (rare in infants, >50 y) • Peritonsillar abscess
• Parapharyngeal abscess
Classification • Cervical abscess
1. Acute catarrhal (spfc) = viral, part of general pharyngitis • AOM
2. Acute follicular = inflammation à crypts à filled w purulent • RF, acute GN
material • Bacterial endocarditis
3. Acute membranous à exudation from crypt à spfc membrane
4. Acute parenchymatous à affects tonsil siubstance = red/enlarged; Vincent’s Angina (Angina Ulcermambranacea)
may “meet in the middle” • Ulceration of mucosa of tonsils, pharynx & mouth
• MO = spirochete (Vincent spirillum) + (symbiotic) fusiform bacillus
Etiology o Short course
• Hematolytic strep pyogenes (1ry or 2ry à viral), Staph, o Good prognosis
Penumococci, H. influenza
Sx
Sx • NO FEVER
• General signs = Fever +/- chills • Unilat pain on swallowing
• Sore throat, dysphagia • FB feeling
• Earache à referred/AOM cx • Tonsil ulcer
• Painful lymphadenitis • Halitosis
• Halitosis
• Hyperemia of pillars, soft palate, uvula Dx
• Enlarged jugulardigastric LNs • Clinical, culture

Dx Tx: 6 day penicillin

• Clinical, lab, culture
N.B. Waldeyer’s Ring
DDx 1. Nasopharyngeal tonsil/adenoids
• Scarlett Fever 2. Palatine tonsil = “the tonsils”
• Mono 3. Lingual tonsil
• Diphtheria 4. Tubal tonsils (in fossa Rosenmuller)
• Agranulocytosis 5. Lateral pharyngeal bands
• Unilat à TB, tumour, abscess, ulceromembranitis 6. Nodules (in post pharyngeal wall)

K. Jury & K. Costello-Toft, 2018 46

19. Chronic Tonsillitis & 2ry Cx. Complications

Chronic Tonsillitis 1. Peritonsillar abscess

• Cx of acute tonsillitis or subclinical tonsillitis • Infection spreads from tonsillar parenchyma à pharyngeal spaces à
• Microabscesses walled off by fibrous tissue cervical phlemon à mediastinitis!
• Children & YA • Sx:
• Risk = chronic inflammation of sinuses or teeth o Pain
o Trismus
1. Chronic Follicular o High fever
• Tonsillar crypts full of infected “cheesy” material o Speech disturbances
• Yellow spots (beads) of pus on medial surface o Swelling
o Protrusion of faucal pillar, soft palate & uvula
2. Chronic Parenchymous
2. Parapharyngeal abscess
• Hyperplasia of lymphoid tissue
3. Intratonsillar abscess à accumulation of pus wi tonsil à swelling
• Very enlarged à interfere w speech, chewing, resp à apnea
4. Tonsilloliths
5. Tonsillar cyst à blockage of a tonsillar crypt
3. Chronic Fibroid
6. Focus of infection à RF, acute GN
• Small but infected tonsils + hx of repeated sore throat
• Small à pressure à expel “cheesy” material Tx
• Drainage
Sx
• Tonsillectomy = after healing
• Recurrent attacks of sore throat/acute tonsillitis
• Chronic irritation of throat & cough
• Halitosis
• Dysphagia, speech issues, choking spells

Dx
• Flushing of ant pillars compared to rest of pharyngeal mucosa
• Enlargement of jugulodiagstric LN à tender in acute attack

Tx
• Supportive à tonsillectomy

K. Jury & K. Costello-Toft, 2018 47

20. Indications for Adenoidectomy & Tonsillectomy 21. Tumours of Mesopharynx & Laryngopharynx (Hypopharynx)

Adenoidectomy Tumours of Oropharynx

1. Adenoid HT à snoring, mouth breathing, apnea, speech sx
2. Recurrent rhinosinusitis 1. Benign Tumours = RARE
3. Chronic 2ry OM assoc’d w adenoid hyperplasia • Papilloma
4. Recurrent ear discharge in benign chronic serous OM à assoc’d w • Hemangioma
adenods hyperplasia • Pleomorphic adenoma
5. Dental malocclusion • Mucous cyst à FB sensation
Tonsillectomy 2. Malignant Tumours
• Post 1/3 of tongue
A. Absolute • Tonsil & tonsillar fossa
1. Recurrent throat infection (>7/y)
• Facuial palatine arch à soft palate & ant pillar
2. Peritonsillar abscess
• Post & lat pharyngeal wall
3. Tonsilltisi à febrile seizure
4. HT of tonsils à AW obstruction, chewing/speech sx
Gross Appearance
5. Suspicion of malignancy
1. Spfc spreading
2. Exophytic
B. Relative
3. Ulcerative
1. Diphtheria carrier, don’t respond to Abx
4. Infiltrative
2. Strep carrier (source of infection à others)
3. Chronic tonsillitis w halitosis (does not resp to med tx) • 1& 3 = palatine arch, mets rare
4. Recurrent strep tonsillitis in px w valvular HD • 3&4 = tongue, tonsil à mets (regional), poorer prognosis

C. As Part of Other Operation Histo

1. Palatopharyngoplasty 1. SCC
2. IX Neurectomy 2. Lymphoepithelioma
3. Removal of Styloid Process 3. Adenocc
4. Lymphomas

Tx
1. Surgery alone
2. Radiation alone
3. Combo of 1&2
4. Chemo alone, adjuvant
5. Palliative

K. Jury & K. Costello-Toft, 2018 48

22. Dysphagia & Its Management by the Family Doctor • Other:
o Bronchoscopy à bronchial cc
Dysphagia = difficulty swallowing, globus sensation o Cardiac catheterization à vasc anomalies
o Thyroid scan à malignancy

Tx
• According to dx

Sx
• Odynophagia = pain on swallowing
• Feeling of FB sensation

Dx
• History
o Onset, progressive
o More to liquids, more to solids
o Intolerance to acidic food or fruit juices
o Any regurgitation
o Aspiration into lungs or nose?
o Aspiration while lying down? At night?
• Clinical exam à examination of oral cavity, oropharynx, larynx,
laryngopharynx can exclude most re-esophageal causes
• Examination of neck, chest, nervous system including CN
• Bloods à Plummer-Vinson syndrome, nutritional status of px
• X-ray chest
• Lateral view neck
• Barium swallow
• Manometric & pH studies
• Esophagoscopy
K. Jury & K. Costello-Toft, 2018 49
C. LARYNX Functions
• Respiration
1. Functional Anatomy of the Larynx. • Phonation
• Cough reflex
• Protection of LRTI: 3 Defense Line
o Protective during swallowing
o Laryngeal closure
o Arytenoid & aryepiglottic folds all come together
• Closure of larynx allows build-up of intrathoracic P à defecation,
lifting, delivery, straining

Blood Supply
• Laryngeal branch of sup thyroid a
• Cricothyroid br of sup thyroid a
• Laryngeal br of inf thyroid a

Innervation
• Recurrent laryngeal N
• Superior laryngeal n
• Motor mm à RLN
o Cricothyroid m à ext laryngeal n
• Sensory
o Above vocal cords = internal laryngeal n
o Below vocal cords = recurrent laryngeal n

• Located in ant compartment of neck, suspended from hyoid bone,

spanning C3 & C6
• Covered ant by infrahyoid mm & laterally by lobes of thyroid gland
• Posterior is the esophagus
• Component of resp tract

K. Jury & K. Costello-Toft, 2018 50

2. Malformations fo the Larynx 8. Laryngeal Cyst
• In aryepiglottic fold à bluish, fluid-filled smooth swelling in
1. Laryngomalacia (congenital laryngeal stridor) = moast common supraglottic larynx
• Excessive flaccidity of supraglottic larynx à suck in w inspiration à
inspiratory stridor +/- cyanosis
• Immature cartilage à self-limiting (~2 y)

2. Congenital Vocal Cord Paralysis

• Birt trauma to recurrent laryngeal n
• CNS anomaly

3. Congenital Subglottic Stenosis

4. Laryngeal Web
• Incomplete recanalization à inspiratory stridor, failure to thrive
• Tx: thick = excision vis laryngofissure, silicone keel & dilatations
o Thin = cut w knife or CO2 laser

5. Subglottic Hemangioma
• Incomplete recanalization ~ 8th week
• Supraglottic ~2%, glottis 755, subglottic 7%
• à 3-6 m à hamangionma ↑ in size à inspiratory stridor, AW
obstruction
• Direct laryngoscopy à blusih-red mass below vocal cords, biopsy +/-
hemorrhea
• Tx = tracheostomy, dexamethasone, CO2 laser if small

6. Laryngo-esophageal Cleft
• Fusion failure à aspiration & pneumonitis, assoc’d w TE fistulas,
laryngomalacia, cleft lip/palate, Downs
• Tx = tracheotomy or endoscopic repair

7. Laryngocele
• Dilation of laryngeal saccule btw thryoide cartilage & ventricle
• Internal,e xternal, combined
• Tx = endoscopic or external incision

K. Jury & K. Costello-Toft, 2018 51

3. Trauma of Larynx, Therapy Dx
• Indirect laryngoscopy
Trauma of Larynx • Direct laryngoscopy
• Lat soft tissue X-ray
Etiology • CT
• Car accident à neck hits wheel • CXR à PTX
• Blow/kick to neck
• Neck striking wire/cable Tx
• Strangulation • Conservative
• Penetration injury à stab, GSQ o Rest & observe
• Slight bruise externally à tear & laceration of mucosa à fracture of o Voice rest
laryngeal framework o Humidify air
o Steroid tx inhibits edema
Pathologic Changes o Abx
• Hematoma & edema of supraglottic or subglottic region • Surgical
• Tears in laryngeal/pharyngeal mucosa à SQ emphysema o Tracheostomy
• Dislocation of cricoarythenoid joint o Open reduction (3-5 d later, not >10 d)
• Dislocation of cricothyroid joint à recurrent laryngeal n paralysis
• Fracture of hyoid
• Feature of thyroid cartilage à transverse/vertical
• Fracture of cricoid
• Fracture of upper tracheal rings
• Separation of trachea from cricoid

Sx
• Resp distress
• Aphonia, hoarseness
• Dysphagia, odynophagia, aspiration
• Larynx pain
• Hemoptysis

External
• Bruises
• Pain on palpation
• SQ emphysema
• Flattening of thyroid prominence
• Fragmental cartilage
• Bony crepitus
K. Jury & K. Costello-Toft, 2018 52
4. Functional Disorders of the Larynx 6. Acute Laryngitis In Childhood
• Dysphona, aphonia, dyspnea (stridor)
1. Acute Epiglottitis = rare, 2-5 y (vaccination!)
1. Nervous à laryngeal paralysis • >90% H. influenza (b) à “cherry red epiglottis”
• Unilateral vs. bilateral
• Central vs peripheral Sx
• Recurrent vs superior (or both) • Inspiratory stridor
• Cyanosis, dyspnea
Etiology • High fever, septic appearance
• Supranuclear (pseudobulbar palsy)
• Nuclear à nucleus ambiguous in medulla (CNX) Dx
• Ghigh vagal lesion à exit from jugular foramen, parapharyngeal • Indirect laryngoscopy
space • Lateral soft tissue X-ray à thumb sign
• Low vagal or recurrent laryngeal n
• Systemic disease à DM, syphilis, diphtheria, toxins, infections Tx
• Idiopathic (30%) • Prophylactic intubation
• Hydration
a) Recurrent Laryngeal N Paralysis • ABx à ampicillin, 3rd gen cephalosporins
• Unilat à ipsilat paralysis of all int m except cricothyroid (ext
laryngeal n) 2. Acute Laryngo-tracheo Bronchitis
o 1/3 asx • Acute inflammation of larynx, tracheal & bronchi
o Sx à vocal changes, no AW/aspiration! • Viral = Parainfluenza 1, 2, RSV à kids 6-3 y
• Bilat = neuritis, surgical trauma (thyroidectomy) à all laryngeal mm • 2ry bacterial infection (G+ cocci)
are paralyzed
o Sx = dysphonia & stridor Sx
• Tx = tracheostomy, surgical repair • URT infection à hoarseness & croup
• High fever
b) Superior Laryngeal n Paralysis (RARE) = +/- pt of combined paralysis • Inspiratory stridor/exp wheeze
• Paralysis of cricothyroid mm + anesthesia of supraglottic area
• Sx = aspiration, ↓ vocal power, cannot sing Tx
• Flaccidity of affected vocal fold à glottis doesn’t close • Hospital
• Abx à ampicillin
c) Combined = vocal cords in intermediate position • Humidification
• Sx = dysphonia, aphonia, aspiration, can’t cough • Steroids
• Tx = tracheostomy, epiglottopexy, laryngectomy • Adrenaline (inhaled)
• Intubation/tracheostomy
2. Myogenic = fibrosis
3. Articular (Anklyosis of arytenoid joints)

K. Jury & K. Costello-Toft, 2018 53

5. Acute & Chronic Inflammation of Larynx 2. Chronic Laryngitis wo Hyperpleasia (Chronic Hyperemic)
• Diffuse inflammatory condition involving whole larynx
1. Acute Laryngitis
• Infectious = common = following URT: viral à 2 bacterial (S. Etiology
pneumonia, H. influenza, S. aureus) • Following incomplete recovery of acute simple laryngitis
• Non-infectious • Chronic inflammation in sinuses, teeth, tonsils
• Occupation & lifestyle
Sx • Persistent trauma of cough
• Hoarseness à lsos of voice • Vocal abuse
• Discomfort/apin in throat
• General sx = cold sx, dry throat, malaise, fever Sx
• Early • Hoarseness
o Erythema & edema • Hacking cough
o Vocal cords white near normal (contrast) • Discomfort & dry cough
• Later
o ↑ hypermedia & swelling Dx
o Vocal cord swelling • Laryngeal examination
o Subglottic involvement
o Secretions w cords Tx
• Cause, rest, steam inhalation, expectorants
Tx
• Vocal test 3. Chronic Hypertrophic/Hyperplastic Laryngitis
• Avoid irritants • Diffuse & symmetrical
• Steam inhalation • Localized (tumour-like)
• Cough suppression • Patho changes start in glotic region à extend to ventricular bands
• Abx
• Analgesia, steroid Sx
• Dusty red, thickened mucosa
• Red, swollen vocal cords à nodular

Tx
• Conservative
• Surgical = 1 cord at a time

K. Jury & K. Costello-Toft, 2018 54

7. Benign Tumours & Precancerous Diseases of Larynx Neoplastic Lesions = only papillomas are common

Non-Neoplastic 1. Squamous Papillomas

• Tumour-like à result of infection, trauma, degeneration
• More frequent a) Juvenile Papillomas
• Viral = HPV 6, 11, 16, 18
1. Vocal Nodules (Singer’s) • Multiple
• On free edge of vocal cord (symmetrically) at junction of ant 1/3 & • Infant, young kids
post 2/3 • Recur after removal
• Pin head size • Glistening white irregular growths à involute at puberty
• Vocal trauma • Hoarseness & stridor
• Hoarseness, vocal fatigue, neck pain • Tx = endoscopic removal, CO2 laser
• Tx = conservative, surgery • CI = tracheotomy à seeding to lower AW

2. Vocal Polyp b) Adult-Onset Papilloma

• Vocal abuse, allergy, smoking (men 30-50) à unilat from same place • Single, smaller, less aggressive (no recurrence)
as nodule • Men 30-50 y
• Soft, smooth, pedunculated • From ant ½ of vocal cord
• Horaseness, large à dysphonia, choking
• Tx = surgical excision 2. Chondroma
• Men 40-60
3. Reinke’s Edema = Bilateral Diffuse Polyposis • Cricoid cartilage à subglottic area à dysphonia
• Collection of edema fluid in subepithelial space of Reinke • Hoarseness, dyspnea, dysphagia, FB sensation
• Vocal abuse, smoking • Tx = endscopic excision
• Diffuse symmetrical swelling of vocal cords
• Tx = vocal cord stripping, 1 cord at a time 3. Hemagioma
o Vocal tx
o Smoking cessation a) Infantile Hemangioma à subglottic
• 50% w hemgioma elsewhere
4. Intubation Granuloma • Tend to involute spontaneously
• Tracheostomy may be needed à resp distress
5. Leukoplakia • Capillary type à CO2 laser

6. Cystic b) Adult Hemagioma à vocal cord, supraglottic larynx

• Ductal, saccular, laryngocele • Hoarseness, dysphonia, dysphagia, rarely bleeding
• Cavernous à NO laser
• Asx à no tx
• Large à steroid, radiation
K. Jury & K. Costello-Toft, 2018 55
4. Granular Cell Tumour
• Schwann cells in post aspect of true vocal folds or arytenoids
• Insidious hoarseness
• 3% malignant potential

5. Glandular Tumour

K. Jury & K. Costello-Toft, 2018 56

8. Malignant Tumours of Larynx 2. Glottic Cancer = MOST COMMON
• Free edge & upper surface of vocal cord
3 Sites • Local spread to ant commissure à other cord
1. Supraglottis • Few lymphatics = NO LN METS
a. Suprahyoid epiglottis, infrahyoid epiglottis • Sx
b. Lat aspect of aryepiglottic folds o Hoarseness
c. Arytenoids o Dysphonia, aphonia à fixation (poor sign)
d. False cords
2. Glottis = true vocal cords, ant post commissure 3. Subglottic Cancer (rarest, 1-2%)
3. Subglottis = up to lower border of cricoid cartilage • Locally invasive à cricothyroid membrane, thyroid gland, neck m
• Fast LN mets à prelaryngeal, pretracheal, paratracheal, lower jugular
Risks • Sx
• Genetic o LATE!
• Smoking & alcohol o Hoarseness à indicates spread
• Previous radiation to neck o Stridor, obstruction
• Occupational à asbestos, mustard gas, chemicals
Dx
Etiology • Neck examination
• 90-95% are SCC • Radiography
• different grades of dediff (cord à well, supraglottic à anaplastic) o CXR
o Contrast laryngogram
1. Supraglottic Cancer o CT
• Less frequent than glottis o MRI
• Epiglottis > false cords >aryepiglottic folds • Direct laryngoscopy
• Spread • Staining & biopsy
o Supraglottic region
o Ifnrahyoid epiglottis & ant ventricular band Tx à see Topic 9
o Early LN mets (rich lymph) à upper & middle jugular LN
o Bilateral mets
• Sx
o Often silent
o Throat pain, dysphagia, referred apin
o Hoarseness
o General malignancy sx

K. Jury & K. Costello-Toft, 2018 57

9. Treatment of Laryngeal Cancer, Surgical Procedures for Laryngeal 10. Dyspnea Caused by Disorders of URT
Carcinoma • Clinical Term à SOB (subjective), breathlessness
• Tx depends on site, extent, LN +/- mets
1. Infectious Origin à URTI (Bacterial, Viral)
1. Radiotherapy • Rhinitis
• Curative à early lesions wo impairment or invasion • Rhinosinusitis, sinusitis
• 90% vocal cord • Nasopharyngitis
• 70-90% exophystic = tip of epiglottis, aryepi folds • Pharyngitis
• ! = fixed cords, subglottic extension, cartilage invasion, LN mets à • Epiglottitis
surgery • Laryngitis
• Laryngotrachitis
2. Surgery • Tracheitis

a. Conservative à preserve voice, avoid permanent trach 2. Non-Infectious Origin

• Cordectomy via laryngofissure • Malformations
• Partial frontolateral laryngectomy • Trauma to larynx
• Partial horizontal laryngectomy • Functional disorders of larynx
• FB
b. Total Laryngectomy • Laryngeal edema
• Entire larynx, hyoid, pre-epiglottic space, strap mm, tracheal rings • Tumours/neoplasms
• Paryngeal wall repair à lower tracheal stump sutured to skin +/- • Stenosis of larynx/URT
block dissection for LN mets
• Indications:
o T3 lesion à cord fixation
o T4 lesion
o Cartilage invasion à thyroid, cricoid
o Bilateral arytenoid involvement
o Post commissure lesion
o Failure of radiotx, conservative surgery
• CI = distant mets

3. Combined Therapy
• Surgical ablation + preop or post-op radiation
• ↓ recurrence

K. Jury & K. Costello-Toft, 2018 58

11. Edema in Larynx 12. Indications for Cricotomy, Tracheostomy + Technique

Laryngeal Edema 1. Cricotomy = opening via crycothyroid membrane

• Edema glottides à but actually involves supraglottic & subglottic • Cricothyrotomy, emergency (mini) tracheostomy à small tube, knife
mucosa puncture
• True edema of vocal cords cocurs rarely • Emergency à time for transport à ER
• Elective à clearance of bronchial secretions
Etiology
• Infections Indications
o Acute epiglottitis, LTB, TB< syphilis of larynx 1. Can’t intubate/ventilate
o Peritonsillar abscess, retropharyngeal abscess, Ludwig’s 2. Severe facial/nasal injuries
angina 3. Massive midfacial trauma
• Trauma 4. Possible cervical spin trauma prevents ventilation
o Surgery 5. Anaphylaxis
o Laryngeal trauma 6. Chemical inhalation injuries
o FB
o Endoscopy, ET intubation 2. Tracheotomy = operative procedure
o Burns • Create surgical AW in cervical traches
• Neoplasms • Emergency
• Allergy • OR (under GA)
o Angioneurotic edema, anaphylaxis • Bedside of criticall ill
• Radiation • Hole btw 3rd & 4th tracheal rings à insertion of tracheostomy tube
• Systemic diseases
o Nephritis, HF, myxedema Indications
1. Bypass obstruction
Sx 2. Neck trauma
• AWO à resp distress, cyanosis 3. SQ emphysema
• Inspiratory stridor 4. Facial fractures
5. Edema
Dx 6. LT mech ventilation
• Indirect laryngoscopy 7. Pulm toilet à suctioning
8. Prophylaxis
Tx 9. Severe sleep apnea
• Intubation
• Tracheostomy Care à maintain AQ, humidity, suction, skin care, pressure, feeding
• Less severe à conservative (cause dependent)
Decannulation à tube should be removed ASAP à previous cx à airtight
• Steroids
dressing

K. Jury & K. Costello-Toft, 2018 59

13. Intubation or Tracheotomy. 14. Diagnosis & Management of Foreign Bodies in URT & LRT
• Kids: 50%, <4 y
1. Intubation • Adults = coma, intoxicated, loose teeth
• Placement of tube into orifice à ET intubation à oro or naso à via
laryngosocope, bronchofibroscope, blind Ingested
• Usually stuck at cricopharyngeus
Indications
• Coins, toys, batteries (EMERGENCY)
1. Coma/intoxicated px unable to protect AW (GCS <8)
2. General anesthesia • Drooling, dysphagia, stridor
3. Dx manipulations of AQ
4. Endoscopic procedures to AQ Aspirated
5. Px who need resp support • Usually stuck at R mainstem bronchus
• Peanuts, carrots, apple core, popcorn, balloons
Pros • Stridor if lodged in trachea
• Reliable maintenance of AQ • Unilat “asthma” if bronchial à misdiagnosed
• Prevent aspiration (if ETT) • Totally occludes AW = cough, lobar pneumonia, atelectasis,
• Easy to aspirate bronchial secretions mediastinal shift, PTX, death
• + P ventilation possible
Sx
Cons • Initial choking/gagging
• Skill + knowledge • Sx-free interval
• Circulatory rxn to intub/extub (pressor) • Later sx à AW obstruction, inflammation, trauma
• Needs anesthesia/sedatuib
• Cuff à trauma Dx
• LT à cx • Hx à coughing, wheezing, choking
• Physical
Difficult AW = 3 unsuccessful attempts • Radiography
• Mouth opening limits à Mallampati, 321 Rule, Cormak o Soft tissue posteroant & lat view
Classification of Laryngeal View (See Anesthesiology for more o CXR
details) o Fluoroscopy
• Poor laryngoscopic visualization o Bronchoscopy
o Chest CT
• Cx of tube insertion
Tx à NPO!!!
2. Tracheotomy
• Laryngeal à Heimlich maneuver à emergency crico/tracheostomy
• LT AW support
• No ET access à trauma, edema, etc. • Tracheal & Bronchial à removal by bronchoscopy (GA),
esophagoscopy

K. Jury & K. Costello-Toft, 2018 60

15. DDx of Cervical Enlargements & Inflammation • Sarcoidosis
• Fungal
• Saladenitis (parotid, submaxillary)

Dx
• Hx
• Physical
• Lab à FNAB
• Imaging:
o CT
o MRI
o U/S
o Radionucleotide scans

1. Neoplastic
• 1ry neck tumour à adenocc, thyroid, lymphoma, lipoma, etc
• Metastasis

2. Congenital/Developmental
• Sebaceous cysts
• Branchial cleft cysts
• Thyroglossal duct cysts
• Lymphangioma/hemagioma
• Ectopic thyroid tissue
• Laryngocele
• Pharyngeal diverticulum
• Thymic cysts

3. Inflammatory
• Reactive Lymphadenopathy à bacterial, viral, granulomatous,
Kawasaki
• TB
• Cat-scratch
K. Jury & K. Costello-Toft, 2018 61
16. Ludovic’s Angina, Parapharyngeal & Retropharyngeal Abscess, 2. Parapharyngeal Abscess
Cervical Phlegmon. • Pharyngomaxillary or lateral pharyngeal space
• Pyramid shape à base of skull, apex at hyoid
1. Ludvovic (Ludwig’s) Angina
• Infection of submandibular space Etiology - infection
• Sublingual component • Pharynx
• Submaxillary & submental compartment à mylohyoid • Teeth
• Ear (petrositis)
Etiology • Other spaces
• Dental infection à 80% • External trauma
• Submandibular sialadenitis
• Injuries to oral mucosa Sx: torticollis, fever, odynophagia, infection signs
• Mandible fracture Anterior Compartment Posterior Compartment
• Micro-org: • Tonsil prolapse • Bulge of pharynx
o Mixed anaerobe-aerobe à common • Trismus à tracheostomy • Paralysis of CN IX, X, XI,
o Alpha-hemolytic Strep, Staph, bacteroides (rarely H. • Ext swelling behind angle of XII, symp
influenza, Pseudomonas) jaw • ! trismus, tonsil

Sx Cx
• Odynopagia +/- trismus • Laryngeal edema à AWO
• Sublingual à swollen floor of mouth • Thrombophlebitis of jug v
• Submax à tender, woody-hard submental & submandibular region • Inf à retropharyngeal space
• Cellulitis à abscess • Inf à mediastinum (along carotid space)
• Tongue may threaten AW • Mycotic aneurysm of carotid
• +/- laryngeal edema • Carotid blow out

Tx Tx
• Systemic Abx • Systemic Abx
• Incision & drainage of abscess à intraoral or extraoral • Drainage of abscess à under GA
• Tracheostomy à AWO o Horizontal incision 2-3 cm below angle of mandible

Cx
• Spread to parapharyngeal, retropharyngeal space à mediastinum
• AWO
• Septicaemia
• Aspiration pneumonia

K. Jury & K. Costello-Toft, 2018 62

3. Retropharyngeal Abscess 17. Corrosive Injury & Stenosis of Esophagus
• Behind pharynx btw buccopharyngeal fascia covering constrictor mm
& prevertebral fascia = skull à bifurcation of trachea 1. Corrosive Injury = acids, alkali, other chemicals, swallowed batteries
• = 2 lat spaces of Gillette à divide by fibrous raphe, contains • Accident
retropharyngeal nodes (disappear at 3-4 y) • Homicide
• Communicates w parapharyngeal space • Suicide
• Nature of burns depends on substance à alkali is worse!
Etiology
• Kids <3 y = Suppuration of retropharyngeal LN 2ry to infection of Stages
adenoids, nasopharynx, post nasal sinuses 1. Stage of acute necrosis
• Adults = trauma (penetrating injury), pus under petrous bone 2. Stage of granulations
3. Stage of strictures
Sx
• Dysphagia & dyspnea à esophagus & trachea obstruction Dx: cause, imaging
• Stridor +/- croupy cough
• Torticollis Mgmt: hospitalization (pharma), standard emergency tx, may require life-
• Bulge in post pharyngeal wall long follow-up

Dx 2. Stenosis à dysphagia, regurgitation, aspiration

• Imaging à soft tissue lat view of neck • Strictures occur when muscular coat is damaged:
o Burns
Tx o Trauma – FB, instrumentation, external
• Abx o GERD = ulceration
• Incision & drainage of abscess o Infection = ulceration
o Usually wo anesthesia à risk of rupture w intubation o Surgical anastomosis
• Tracheostomy (AWO) o Congenital (<1/3)

4. Cervical Phlegmon Dx: Ba swallow, OGD

• Diffuse spreading inflammatory process w formation of pus
Tx
• Bac cause = Staph, Strep, Pneumococci, anaerobes
• Dilation w bougies
Tx • Gastrotomy
• Remove cause + prevention of residual disease à drainage • Surgery
• Avoid spreading pus!!!

K. Jury & K. Costello-Toft, 2018 63

18. Foreign Bodies in Pharynx & Esophagus 19. Diseases of Salivary Glands
• Inflammatory or non-inflammatory
1. Tonsil = sharp fish bone or needle, easily observed & removed • Usually involves major glands
2. Base of tongue/vallecula à observed by mirror examination
3. Pyriform fossa Sx
4. Esophagus à coin, meat, chicken bone, marble, etc • Swelling à acute inflammatory sialadenitis
• Pain à sialadenitis, tumour
Ingested • Dryness à Sjogren’s
• Usually stuck at cricopharyngeus • Purulent discharge à sialadenitis, abscess
• Coins, toys, batteries (EMERGENCY) • Facial n palsy à malignancy
• Drooling, dysphagia, stridor
Dx
Etiology • Palpation, X-ray, CT, US, MRI, endoscopy, FNA
• Age à usually kids
• Loss of protective mech à LOC, seizures, deep sleep, inotixcation 1. Trauma
• Carelessness 2. Mumps
• Narrowed esophgeal lumen à stricture/cc 3. Acute Suppurative Parotitis = S. aureus, elderly, ill
• Psychotics 4. Sialectasis à dilation, stasis à infection
5. Granulomatous disease (TB, sarcoidosis, actinomycosis)
Sx 6. Salivary calculi (90% submandibular, duct, parenchyma)
• Same as in Topic 14 7. Sjogren’s (AI, 1ry, 2ry)
• Tenderness in lower pt of neck on R/L of trachea 8. Neoplasms (Benign)
• Pooling of secretion in pyriform fossa on indirect laryngoscopy that a. Epithelial à pleomorphic adenoma, adenolymphoma
do NOT disappear on swallowing b. Mesenchymal à hemangioma, lymphangioma, lipoma,
• FB may be seen protruding from the esophageal opening in the neurofibroma
postcricoid region 9. Malignant Tumours
a. No pain, skin involvement, fixation, no inflammation, facial n
Dx involvement
• Plain X-rays, fluoroscopy b. Muco-epidermoid cc, adenois cyst cc, acinic cell cc

Tx
• Esophagoscopic removal à under GA
• Cervical esophagotomy à impacted or those w sharp hooks
• Transthoracic esophagotomy
• Operative
o Pain & tenderness in abdomen
o FB show no progress on serial X-rays after a few dd
o >5 cm in child <2 y

K. Jury & K. Costello-Toft, 2018 64

20. Stenosis of Larynx & URT 21. DDx of Dysphonia

1. Congenital Subglottic Stenosis = failure of recanalization 1. Organic Dysphonia

• Membranous • Laryngitis
• Cartilaginous • Tumour
• Mixed • Trauma
• Endocrine
Grades • Hematologic
• I = <70% obstruction • Iatrogenic
• II = 70-90%
• III = 91-99% 2. Functional Dysphonia
• IV = complete • Emotional females

Sx 3. Spasmodic Dysphonia
• Biphasic stridor • Excessive tension in laryngeal mm
• Normal cry
• FTT 4. Chronic Dysphonia
• Voice overuse
Dx • Surgery
• Subglottic diameter <4 mm full term, <3 mm preterm • Chronic laryngitis
• Endoscopy, CXR • GERD

Tx Tx
• Endoscopic vs. open procedure for correction • Conservative
• Resolution of infection
2. Acquired Laryngeal Stenosis • PPI à GERD
• ETT à pressure necrosis • Rarely, surgery
• Postop à pressure necrosis
• Granulomatous disease = TB, Sarcoidosis, Wegner’s DDx
• Infections • Inflammation
• Trauma = FB, burns, blunt trauma • Tumours
• Systemic = CT disorders, GERD, radiation • Trauma
• Neoplasm = chondroma, fibroma, malignancy • Paralysis
• Idiopathic • Fixation of cords
• Congenital
Tx • Functional
• Supportive à surgery

K. Jury & K. Costello-Toft, 2018 65

22. Palpation of Neck & Its Consequence in Practice. 4. When Nodes are Palpable:
• Important particularly in suspected head & neck malignancies • Location, #, size
• Need systematic approach • Consistency
o Hard = metastatic
1. Neck nodes are better palpated while standing behind the px o Firm & rubbery = lymphoma
o Soft = hyperplastic nodes & metastatic melanoma
2. Neck is slightly flexed to achieve relaxation of muscles • Discrete/matted
• Tenderness à inflammatory nodes are tender
3. Systematic Order of Node Examination • Mobility à check fixation in both vertical & horizontal planes
• Upper horizontal chain à submental, submandibular, parotid, facial,
postauricular & occipital nodes 5. Thyroid Gland
• External jugular chain à spfc to sternomastoid m • Inspect neck looking for thyroid à visible? Symmetrical?
• Internal jugular à upper, middle, lower groups, many lie deep to • Move to stand behind px
sternomastoid m which may need to be displaced posteriorly • Identify cricoid cartilage w fingers of both hands
• Spinal accessory chain • Move downward 2-3 tracheal rings while palpating isthmus
• Transverse cervical chain • Move laterally from midline while palpating lobes of thyroid
• Anterior jugular chain • Note size, symmetry, position of lobes +/- presence of nodules
• Juxtavisceral chain à prelaryngeal, pretracheal & paratracheal o Normal gland is often not palpable!!!

K. Jury & K. Costello-Toft, 2018 66

D. PRACTICAL TOPICS
General Info: [Link]

1. Examination of the External Auditory Meatus & Ear Drum

[Link]

[Link]

2. Examination of Hearing by Means of Tuning Forks

• See: Topic 3E

3. Audiograms
• See: Topic 3E
[Link]

4. Measurement of Hearing Loss

• See: Topic 3E

5. Examination of Spontaneous Vestibular Symptoms

[Link]
function-testing-to-assess-and-treat-vestibular-system-
[Link]?sfvrsn=2

[Link]
[Link]

6. Cleaning of External Meatus

[Link]
procedures/cleaning-the-external-auditory-meatus

K. Jury & K. Costello-Toft, 2018 67